INTRODUCTION

A stroke is a term used to describe neurologic changes caused by an interruption in the blood supply to a part of the brain. A stroke is caused by the interruption of the blood supply to the brain, usually because a blood vessel bursts or is blocked by a clot. This cuts off the supply of oxygen and nutrients, causing damage to the brain tissue. The most common symptom of a stroke is sudden weakness or numbness of the face, arm or leg, most often on one side of the body. Other symptoms include: confusion, difficulty speaking or understanding speech; difficulty seeing with one or both eyes; difficulty walking, dizziness, loss of balance or coordination; severe headache with no known cause; fainting or unconsciousness. The effects of a stroke depend on which part of the brain is injured and how severely it is affected. A very severe stroke can cause sudden death. The two major types of stroke are ischemic and hemorrhagic. Ischemic stroke is caused by a thrombotic or embolic blockage of blood flow to the brain. Bleeding into the brain tissue or the subarachnoid space causes a hemorrhagic stroke. Ischemic strokes account for approximately 83% of all strokes. The remaining 17% of strokes are hemorrhagic. Cerebrovascular disorders are the third leading cause of death in the United States and account for approximately 150,000 mortalities annually. An estimated 550,000 people around the world experience a stroke each year. Stroke is both the leading cause of adult disability and the primary diagnosis for long term care. In the UK, it is the second most common cause of death, the first being heart attacks and third being cancer. It is the number two cause of death worldwide and may soon become the leading cause of

death worldwide. Stroke is also the second leading cause of death in the Philippines with a total of 51,680 according to DOH(site reference). Along with this are 37, 092 who survived with it. There are millions of stroke survivors living with varying degree of disability in the world. Along with a high mortality rate, strokes produce significant morbidity in people who survive them. Of the stroke survivors, 31% require assistance with self care, 20% require assistance with ambulating, 71% have some impairment in vocational ability up to 7 years following the stroke, and 16% are institutionalized. We decided to use this as a subject for our case study because as what we all know this kind of illness is said to be a silent killer if prompt medical attention is unmet. That is why we want to know the root cause of such disease in order for us to know how we could intervene and play our role as a nurse. We believe that by studying this case we will gain more information and knowledge about the disease and will lead us to a certain perception as to how we will manage and care if ever we will experience again patients with the same disease.

should be all about study

OBJECTIVES
General Objectives: To conduct a thorough and comprehensive study about Mr. Ek’s disease according to data that was gathered by conducting a series of interviews and through the use of data gathered from extensive research.

Specific Objectives:
• •

To organize our patient’s data for the establishment of good background information To show the family health history as well as the history of past and present illness for the knowledge of what could be the predisposing factors that might contribute to the patient’s illness

To present the Family’ Genogram containing information that will help out in tracing hereditary risk factors

To trace the psychological development of our patient through analysis of different developmental theories with comparison to the patient’s data

To give different definitions of the complete diagnosis of our patient for better understanding of unfamiliar terms

To present the data from the Physical assessment performed on our patient for a good interview of his over-all health

To elaborate on the anatomy and physiology of different organs involved and affected during CVA

To establish whether several factors, signs and symptoms are present or absent in our patient

To organize a flow chart showing the pathophysiology of CVA for a clear visualization of how CVA affects a person

To list the different orders of the physicians assigned to our patient together with their rationale for a general knowledge of what consists of the medical management for CVA

To present the different results of our patient’s diagnostic exams together with comparisons of normal values for the understanding of what changes during the disease

To present the different drugs used by our patient to have a better understanding of its functions and purposes

• • • • • •

To analyze the different nursing theories that can be applied to our patient To come up with the different Nursing Care Plans applicable to our patient To formulate an appropriate discharge plan To create a reasonable prognosis basing on the gathered data To have our over-all Conclusion and recommendations about the case study To gather all the references used upon making this case study

Patients’s Data
Patient’s Code name: Mr. Eks Age: 48 y.o.

Birthdate: April 21,1961 Birth place: Davao Oriental Sex: Male Nationality: Filipino Religion: Roman Catholic Civil Status: Married Occupation: Ward: Male Ward Date of Admission: April 20, 2009 Time of Admission: 12:30 pm Vital Signs on Admission: BP: RR: Temp: PR: Mode of Arrival: Stretcher Admitting Doctor: Dr. Mary Joy Bayocol, MD Chief Complaint: Body Weakness Admitting Diagnosis: Final Diagnosis: Cerebrovascular accident, Infarct, Left middle cerebral artery

Family Background
Mr. Eks, a 48-year old male, was born in Davao Oriental on April.21, 1961. He is currently residing at Cateel, Davao Oriental. They are 6 in the family including his

parents. He is the third child among the four children. Our patient was completely immunized since he received the needed immunizations before he reached 1 year old. He finished elementary and high school at Maryknoll School at Cateel, Davao Oriental. Our patient decided to study in college at Manila, but sad to say they said that he was tired of going to school and decided to stop. Mr. Eks has been married for 9 years with Mrs. Eks. Throughout their marriage, they had 2 offsprings. Their eldest is 7 years old and their youngest is 6 years old and they are currently studying at Maryknoll elementary, Davao Oriental. According to Mrs. Eks, she decided to work on abroad at Israel to meet their families’ needs. Mr. Eks and his 2 children are currently living in his nephew’s house at Cateel. Upon interview with Mrs. Eks, Mr. Eks was recommended by his neurosurgeon in Cateel, Dr. Aguhitas, to travel in Limso for the specialization of his illness which is “stroke”.

Lifestyle:
Through Mr. Eks wife, we were able to formulate Mr. Eks activities during his day before his illness took place. She said that Mr. Eks usually wakes up @ 4am and eats breakfast @ 7 am. After eating, he uses his bicycle as his mode of transportation in going to his farm. His travel time going there is 30 mins and spends his entire day in the farm. He goes home at around 5pm, but sometimes he stops by at his friend’s house to have a drink (alcohol beverages). In a week, he drinks twice or thrice but does not smoke.

Diet:
Mrs. Eks verbalized that they usually have vegetables, fish and rice for their meal. However, they feel eating roasted pig whenever they like it. Mr. Eks likes fruits for dessert like mango, papaya and watermelon.

History of Past Illness:
Mr. Eks Mother said that at the age of 17, he underwent cardiac surgery at the Philippine Heart Center in Manila. It was due to his Congenital Heart Disease which he inherited from his mother. Before the heart surgery took place, Mr. Eks experienced serious chest pain then they sought for medical attention and was diagnosed of having Congenital Heart Disease. Mrs. Eks mother said that after the surgery Mr. Eks cannot tolerate heavy workload and stress but his condition improved after how many years of complying with the recommended health regimen. On October 4,2008, Mr. Eks wife said that he had his first mild stroke but it didn’t affect his health that much. He resumed doing his activities of daily living the day after the mild stroke.

History Of Present Illness:
April 16,2009 at Cateel, Mr. Eks spends his usual activities for the day. He went to the farm for his work then came backto poblacion to visit a friend. He drinks 1Liter of

sprite and sang 1 song from the videoke. While singing, he suddenly collapsed and was brought and admitted to the nearest hospital. Due to lack of facilities, he was referred by Dr. Aguhitas to Ricardo Limso Hospital or April 20,2009. Mr. Eks experienced visual disturbance @ his right eye because he is having hemiparesis in which his right side of his body is weak.

Effect to the family
According to Mrs. Eks, his husband’s condition had greatly affected their family. At first they had a hard time accepting his condition but they had eventually learned to accept it. Emotionally, it affected them because they know that Mr. Eks' condition is serious and that there is always a possibility that they would lose him. Financially, it had affected them because of his hospitalizations, medications and other treatments he had to undergo. However, their family members including other relatives, are always ready to help/support them financially and emotionally.

DEVELOPMENTAL DATA

Theorist Erik Erikson’s Psychosocial Theory Development of Erik

Theory

Stage

Erikson Integrity Vs. Despair that (45 years old

Result ands Justification Due to Mr. Eks’ to

theorized

and inability

development is a above) lifelong

verbalize, the group

process A person who can look has opted to rely on

and does not end back on good times with the verbalizations of with the cessation gladness, on hard times his of adolescence. with self – respect, and others. significant

Just as physical on mistakes and regrets growth patterns with forgiveness, will Mr. Eks has

can be predicted, find a new certain psychosocial tasks must

sense of positively achieved stage of His

integrity and a readiness this for whatever life

or development.

be death may bring.

wife said that his had

mastered in each developmental

A person caught up in husband

old sadness, unable to mentioned in one of conversations

stage. The greater forgive themselves or their the task others for

perceived that he is happy and

achievement, the wrongs, and dissatisfied contented with what healthier the with the life, they’ve he and his family

personality of the led, will easily drift into have even if there person however, depression and despair. have been a lot of in their

failure to achieve A positive outcome in struggles

a task influences this stage is achieved if lives. His mother the person’s the person gains a self said that she saw in

ability to achieve fulfillment of about life his son how he was the next task. and a sense of unity able to handle the within himself and problems that came

others. That way, he can his way and that she

Definition of Complete Diagnosis Cerebrovascular Accident
-

A sudden, nonconvulsive focal neurologic deficit.

Reference: Pathophysiology (the biologic basis for disease in Adults and Children) 2nd Ed. By McCance and Huether.

Cerebrovascular Accident

-

An infarction of brain tissue that results from lack of blood. Tissue necrosis may be an outcome of total occlusion of a cerebral blood vessel by atheroma or embolus, or it may be the consequence of a ruptured cerebral vessel.

Reference: Pathopysiology for the Health Professions by Barbara E. Gould

Cerebrovascular Accident
-

Is a sudden impairment of cerebral circulation in one or more of the blood vessels supplying the brain. CVA interrupts or diminishes oxygen supply and commonly causes serious damage or necrosis in brain tissues.

Reference: Handbook of Medical-Surgical Nursing 3rd Ed. By McCann, Springhouse

Cerebrovascular Accident
-

The sudden death of some brain cells due to lack of oxygen when the blood flow to the brain is impaired by blockage or rupture of an artery to the brain. A CVA is also referred to as a stroke.

Reference: http://www.medterms.com/script/main/art.asp?articlekey=2676

Cerebrovascular Accident
Also known as a stroke, is an acute neurologic injury whereby the blood supply to a part of the brain is interrupted, either by a clot in the artery or if the artery bursts. The result is

that the part of the brain perfused by that artery no longer can receive oxygen carried by the blood and it dies (becomes necrotic) with cessation of function from that part of the brain. In addition to tissue death, hemorrhages also cause damage from physical impingement of blood on the brain tissue. Stroke is a medical emergency and can cause permanent neurologic damage or even death if not promptly diagnosed and treated. It is the third leading cause of death and adult disability in the US and industrialized European nations. Reference: http://psychology.wikia.com/wiki/Cerebrovascular_accident

Physical assessment
Patient’s Name: Mr. Eks Age: 48 y.o. Sex: Male Ward: Male Ward (Limso Hosp.)

General Survey:

Our patient, Mr. Eks was assessed on April 30, 2009 at 5:00pm. He was received lying on bed awake. He has an ongoing IVF of # 15 PLR 1 liter regulated @20 drops/min. infusing well at R Basilic vein at 900cc level. With Nasogastric inserted @ R nostril, patent with distal end closed. He has an endomorphic body structure. He has a Right-sided body weakness.

Vital signs:
5:00 pm BP- 130/90 mmHg PR- 68 bpm RR- 25 bpm Temp.- 38.1 °C

Skin
Skin was generally uniform in color- tan, has a smooth texture and has a good skin turgor as skin goes back to its previous state after being pinched and with a capillary refill of 2 seconds. Nails were properly trimmed and no traces of dirt were noted. Upon touching, the skin on his forearm is warm.

Head

Our patient’s head is normocephalic. Presence of hair was noted in the head and in the upper and lower extremities. He has black hair and evenly distributed. Upon observation, there is a presence of dandruff noted. Lesions, bleeding and bruises were not seen upon inspection.

Eyes
The sclera is moist and slightly yellowish in color. The iris appears to be black on both eyes. He has an isocoric pupil reaction of 2mm round and reactive to light and accommodation. Both eyes move in unison, no signs of scratches and discharges on both eyes noted. Upon interviewing with his wife, she said that he can see both near and far objects by not having difficulties in reading in far and near texts.

Ears
The shape of the pinnaes are oval and with no discharges noted. Upper margin of the pinnaes are in line with the outer canthi of the eyes. Ears are firm and non-tender. Signs of lesions, lacerations, swelling and bruises were not seen upon inspection. He was able to response when instructed to do so, which reveals that he does not have any hearing problems.

Nose
With Nasogastric Tube noted, inserted @ right nostril, patent with distal end closed. External surface of the nose is smooth and oily. Nasolabial folds are symmetrical.

Nostrils are also symmetrical with no flaring and discharges noted. Nasal hairs are present upon inspection. Nasal septum is not deviated. Both nostrils are patent. No signs of tenderness were noted.

Mouth
Outer lips are symmetrical in contour. Upper and lower lips are brown in color. No lesions or edema were noted. Teeth were not complete. Buccal mucosa appears pinkish and smooth. Tongue is in midline and pinkish in color. Gums are slightly brown in color, no bleeding or ulcerations noted. Tonsils were not inflamed and uvula is also in midline. Patient was on diet as tolerated and was observed to eat crackers with easy mastication and no dysphagia. . Patient was on oral feeding of 250cc and flushed with water of 250cc via NGT every 3hours with aspiration precaution. With gelatin cubes PRN/orem to exercise his mastication process.

Neck
The neck of our patient can move easily without any difficulty, which includes right and left lateral, right and left rotation, flexion except hyperextension. Neck can properly support the head. No signs of enlargement and masses on the thyroid. Carotid pulse is palpable. No signs of swelling or enlargement of the lymph nodes. No deformities noted.

Chest and Lungs
Chest muscle expansion during inspiration and relaxation during expiration are symmetrical and painless. A Scar was noted in midline with the sternum until to the xiphoid process indicating that he underwent an open heart surgery during his teenage life. There were no other signs of scars and lesions were noted. He was not in respiratory distress. Respiratory rate is 25 cycles per minute and rhythm was irregular. Upon auscultation, presence of crackles were noted indicating he has a productive cough.

Abdomen
Abdomen is soft, non-tender and globular in shape. There were no scars and lesions noted upon inspection. No discharges were noted on his umbilicus. Bowel sounds are normoactive with 11 sounds counted within one minute.

Genito-Urinary
With condom catheter attached to urobag draining with yellow amber colored urine and diaper in case of defecation. His total urine output for 8 hours was about 640cc and was able to defecate six times with an output of approximately 1500cc.

Upper extremities

Patient’s upper limbs, shoulders and arms were symmetrical. No tenderness noted on the bones of the wrist and fingers. No deformities and swelling noted. With Right sided hemiparesis, he couldn’t move his right shoulder and arm. The patient has a weak grip in the Left hand when he was asked to squeeze one of the student nurse’s hands. No structural deviations noted. Mr. Eks was undergoing venoclysis with IVF of # 15 PLR 1 liter regulated @20 drops/min. infusing well at R Basilic vein at 900cc level.

Lower Extremities
Both legs of the patient are symmetrical. The Left leg can stretch, flex, rotate, extend and bend without any difficulty except for the Right leg. No signs of deformities, lesions, lacerations, bruises and bleeding were seen upon inspection. Patient has difficulty ambulating because of right sided body weakness.

Neurological Assessment
Pupil Size (left): 2mm (right): 2mm Reaction (right): brisk (left): brisk Motor

Handgrip (left): Strong (Right): Absent Leg Movement (left): Moderate (Right): Absent Level of consciousness Eye opening: 4 (spontaneous) Best verbal response: 2 (incomprehensible) Best motor response: 6 (Obeying) Reactive Level Scale: 1 (alert, fully conscious) Glasgow Coma Scale: 12

Anatomy and Physiology
Human Brain

The anatomy of the brain is complex due its intricate structure and function. This amazing organ acts as a control center by receiving, interpreting, and directing sensory information throughout the body. There are three major divisions of the brain. They are the forebrain, the midbrain, and the hindbrain.

Anatomy of the Brain: Brain Divisions
The forebrain is responsible for a variety of functions including receiving and processing sensory information, thinking, perceiving, producing and understanding language, and controlling motor function. There are two major divisions of forebrain: the diencephalon and the telencephalon. The diencephalon contains structures such as the thalamus and hypothalamus which are responsible for such functions as motor control, relaying sensory information, and controlling autonomic functions. The telencephalon contains the largest part of the brain, the cerebral cortex. Most of the actual information processing in the brain takes place in the cerebral cortex. The midbrain and the hindbrain together make up the brainstem. The midbrain is the portion of the brainstem that connects the hindbrain and the forebrain. This region of the brain is involved in auditory and visual responses as well as motor function.

The hindbrain extends from the spinal cord and is composed of the metencephalon and myelencephalon. The metencephalon contains structures such as the pons and cerebellum. These regions assists in maintaining balance and equilibrium, movement coordination, and the conduction of sensory information. The myelencephalon is composed of the medulla oblongata which is responsible for controlling such autonomic functions as breathing, heart rate, and digestion. • • • Prosencephalon - Forebrain Mesencephalon - Midbrain o Diencephalon o Telencephalon Rhombencephalon - Hindbrain o Metencephalon o Myelencephalon

Anatomy of the Brain: Structures
The brain contains various structures that have a multitude of functions. Below is a list of major structures of the brain and some of their functions. Basal Ganglia
• •

Involved in cognition and voluntary movement Diseases related to damages of this area are Parkinson's and Huntington's

Brainstem
• •

Relays information between the peripheral nerves and spinal cord to the upper parts of the brain Consists of the midbrain, medulla oblongata, and the pons

Broca's Area
• •

Speech production Understanding language

Central Sulcus (Fissure of Rolando)

Deep grove that separates the parietal and frontal lobes

Cerebellum
• •

Controls movement coordination Maintains balance and equilibrium

Cerebral Cortex

• • •

Outer portion (1.5mm to 5mm) of the cerebrum Receives and processes sensory information Divided into cerebral cortex lobes

Cerebral Cortex Lobes
• • • •

Frontal Lobes -involved with decision-making, problem solving, and planning Occipital Lobes-involved with vision and color recognition Parietal Lobes - receives and processes sensory information Temporal Lobes - involved with emotional responses, memory, and speech

Cerebrum
• •

Largest portion of the brain Consists of folded bulges called gyri that create deep furrows

Corpus Callosum • Thick band of fibers that connects the left and right brain hemispheres

Cranial Nerves

Twelve pairs of nerves that originate in the brain, exit the skull, and lead to the head, neck and torso

Fissure of Sylvius (Lateral Sulcus)

Deep grove that separates the parietal and temporal lobes

Limbic System Structures
• •

Amygdala - involved in emotional responses, hormonal secretions, and memory Cingulate Gyrus - a fold in the brain involved with sensory input concerning emotions and the regulation of aggressive behavior Fornix - an arching, fibrous band of nerve fibers that connect the hippocampus to the hypothalamus Hippocampus - sends memories out to the appropriate part of the cerebral hemisphere for long-term storage and retrievs them when necessary Hypothalamus - directs a multitude of important functions such as body temperature, hunger, and homeostasis

Olfactory Cortex - receives sensory information from the olfactory bulb and is involved in the identification of odors Thalamus - mass of grey matter cells that relay sensory signals to and from the spinal cord and the cerebrum

Medulla Oblongata • Lower part of the brainstem that helps to control autonomic functions

Meninges

Membranes that cover and protect the brain and spinal cord

Olfactory Bulb • • Bulb-shaped end of the olfactory lobe Involved in the sense of smell

Pineal Gland
• •

Endocrine gland involved in biological rhythms Secretes the hormone melatonin

Pituitary Gland
• •

Endocrine gland involved in homeostasis Regulates other endocrine glands

Pons • Relays sensory information between the cerebrum and cerebellum

Reticular Formation
• •

Nerve fibers located inside the brainstem Regulates awareness and sleep

Substantia Nigra • Helps to control voluntary movement and regualtes mood

Tectum

The dorsal region of the mesencephalon (mid brain)

Tegmentum

The ventral region of the mesencephalon (mid brain).

Ventricular System - connecting system of internal brain cavities filled with cerebrospinal fluid

Aqueduct of Sylvius - canal that is located between the third ventricle and the fourth ventricle Choroid Plexus - produces cerebrospinal fluid Fourth Ventricle - canal that runs between the pons, medulla oblongata, and the cerebellum Lateral Ventricle - largest of the ventricles and located in both brain hemispheres Third Ventricle - provides a pathway for cerebrospinal fluid to flow

• •

• •

Wernicke's Area • Region of the brain where spoken language is understood

Motor Functions
The motor system of the brain and spinal cord is responsible for maintaining the body’s posture and balance; as well as moving the trunk, head, limbs, tongue, and eyes: and communicating through facial expressions and speech. Reflexes mediated through the spinal cord and brainstem is responsible for some body movements. They occur without conscious thought. Voluntary movements, on the other hand, are movements consciously activated to achieve a specific goal, such as walking or typing. Although consciously activated, the details of most voluntary movements occur automatically. After walking begins, it is not necessary to think about the moment-to-moment control of every muscle because neural circuits in the reticular formation automatically control the limbs. After learning how to perform complex tasks, such as typing, they can be performed relatively automatic. Voluntary movements result from the stimulation of upper and lower motor neurons. Upper motor neurons have cell bodies in the cerebral cortex. The Axons of upper motor neurons from descending tracts that connects to lower motor neurons. Lower motor neurons have cell bodies in the anterior horn of the spinal cord gray matter or in cranial nerve nuclei. Their axons leave the central nervous system and extend through spinal or cranial nerves to skeletal muscles. Lower motor neurons are the neurons forming the motor units.

Motor areas of the cerebral cortex

The motor areas are located in both hemispheres of the cortex. They are shaped like a pair of headphones stretching from ear to ear. The motor areas are very closely related to the control of voluntary movements, especially fine fragmented movements performed by the hand. The right half of the motor area controls the left side of the body, and vice versa. Two areas of the cortex are commonly referred to as motor:
• •

Primary motor cortex, which executes voluntary movements Supplementary motor areas and premotor cortex, which select voluntary movements.

In addition, motor functions have been described for: • • Posterior parietal cortex, which guides voluntary movements in space Dorsolateral prefrontal cortex, which decides which voluntary movements to make according to higher-order instructions, rules, and self-generated thoughts.

Descending tracts
The most important descending spinal tract originates in the cerebral cortex and is called the corticospinal tract (see Figure 1-5). The other major descending spinal tracts worth mentioning are: the tectospinal tract arising from the superior colliculus, the rubrospinal tract arising from the red nucleus in the mid-brain, the vestibulospinal tract with its nuclei located in the floor of the fourth ventricle, and the reticulospinal tract arising from the reticular formation in the pons and the medulla. The cortico-bulbar tract which is associated with cranial nerves will not be described in this review of neuroanatomy as it is not prominently employed in the treatment of patients.

1. The corticospinal system (pyramidal system)
The corticospinal tract supplies impulses to most of the voluntary muscles. It originates in the precentral gyrus of the cerebral cortex (area 4). The axons pass through the internal capsule and descend to the mid-brain where they form the crus cerebri (basis pedunculi). In the medulla oblongata, 80 to 90 percent of the fibers decussate to the opposite side and descend in the spinal cord where they form the lateral corticospinal tract. In the spinal cord, the axons of the lateral corticospinal tract are located internal to the posterior spinocerebellar tract and posterior to the lateral spinothalamic tract. The lateral corticospinal tract irradiates branches at all levels of the spinal cord. The fibers enter the gray matter where they synapse in the ventral horn with second-order neurons. The latter emerge from the spinal cord in the ventral spinal roots and supply the voluntary muscles through the peripheral nerves. The remainder of the corticospinal tract which does not cross over in the medulla oblongata divides into two separate tracts: the anterior corticospinal tract and the anterolateral corticospinal tract. The axons of the anterior corticospinal tract descend uncrossed into the spinal cord. They occupy an antero-medial position in the anterior white commissure and are contiguous to the anterior median fissure. Most of the fibers of the anterior corticospinal tract descend to the upper cervical spine where they cross in the anterior white commissure. The fibers enter the gray matter where they synapse in the ventral horn with second-order neurons.

The anterolateral corticospinal tract is the smallest of the three descending tracts. The fibers descend in the lateral funiculus and remain uncrossed in the entire course of the tract. The axons of the anterolateral corticospinal tract synapse in the ventral horn with second-order neurons. It should be emphasized that the pyramidal or voluntary muscle system is made of a two-neuron system. The neurons of the corticospinal tracts leaving the precentral gyrus and descending in the spinal cord to terminate their course in the ventral horn are called upper motor neurons. The second-order neurons leaving the spinal cord to supply the voluntary muscles are called lower motor neurons. The distinction between upper and lower motor neurons paralysis is important in clinical neurology.

Basal nuclei

The basal nuclei are a group of functionally related nuclei. Two primary nuclei are the corpus striatum, located deep within the cerebrum, and the substantia nigra, a group of darkly pigmented cells located in the midbrain.

Anatomy of cerebral circulation
Arterial supply of oxygenated blood Four major arteries and their branches supply the brain with blood. The four arteries are composed of two internal carotid arteries (left and right) and two vertebral arteries that ultimately join on the underside (inferior surface) of the brain to form the arterial circle of Willis, or the circulus arteriosus. The vertebral arteries actually join to form a basilar artery. It is this basilar artery that joins with the two internal carotid arteries and their branches to form the circle of Willis. Each vertebral artery arises from the first part of the subclavian artery and initially passes into the skull via holes (foramina) in the upper cervical vertebrae and the foramen magnum. Branches of the vertebral artery include the anterior and posterior spinal arteries, the meningeal branches, the posterior inferior cerebellar artery, and the medullary arteries that supply the medulla oblongata. The basilar artery branches into the anterior inferior cerebellar artery, the superior cerebellar artery, the posterior cerebral artery, the potine arteries (that enter the pons), and the labyrinthine artery that supplies the internal ear. The internal carotids arise from the common carotid arteries and pass into the skull via the carotid canal in the temporal bone. The internal carotid artery divides into the middle and anterior cerebral arteries. Ultimate branches of the internal carotid arteries include the ophthalmic artery that supplies the optic nerve and other structures associated with the eye and ethmoid and frontal sinuses. The internal carotid artery gives rise to a posterior communicating artery just before its final splitting or bifurcation. The posterior communicating artery joins the posterior cerebral artery to form part of the circle of Willis. Just before it divides (bifurcates), the internal carotid artery also gives rise to the choroidal artery (also supplies the eye, optic nerve, and surrounding structures). The

internal carotid artery bifurcates into a smaller anterior cerebral artery and a larger middle cerebral artery. The anterior cerebral artery joins the other anterior cerebral artery from the opposite side to form the anterior communicating artery. The cortical branches supply blood to the cerebral cortex. Cortical branches of the middle cerebral artery and the posterior cervical artery supply blood to their respective hemispheres of the brain. The circle of Willis is composed of the right and left internal carotid arteries joined by the anterior communicating artery. The basilar artery (formed by the fusion of the vertebral arteries) divides into left and right posterior cerebral arteries that are connected (anastomsed) to the corresponding left or right internal carotid artery via the respective left or right posterior communicating artery. A number of arteries that supply the brain originates at the circle of Willis, including the anterior cerebral arteries that originate from the anterior communicating artery. In the embryo, the components of the circle of Willis develop from the embryonic dorsal aortae and the embryonic intersegmental arteries. The circle of Willis provides multiple paths for oxygenated blood to supply the brain if any of the principal suppliers of oxygenated blood (i.e., the vertebral and internal carotid arteries) are constricted by physical pressure, occluded by disease, or interrupted by injury. This redundancy of blood supply is generally termed collateral circulation. Arteries supply blood to specific areas of the brain. However, more than one arterial branch may support a region. For example, the cerebellum is supplied by the anterior inferior cerebellar artery, the superior cerebellar artery, and the posterior inferior cerebellar arteries. Venous return of deoxygenated blood from the brain Veins of the cerebral circulatory system are valve-less and have very thin walls. The veins pass through the subarachnoid space, through the arachnoid matter, the dura, and ultimately pool to form the cranial venous sinus. There are external cerebral veins and internal cerebral veins. As with arteries, specific areas of the brain are drained by specific veins. For example, the cerebellum is drained of deoxygenated blood by veins that ultimately form the great cerebral vein. External cerebral veins include veins from the lateral surface of the cerebral hemispheres that join to form the superficial middle cerebral vein.

Etiology
Factor Gender Rationale Men are more common on having CVA because of the lifestyle, especially on alcohol intake. An individuals’ risk may increase if a maternal or paternal relative has had a stroke. Possible mechanisms include: genetic heritability of risk factors or susceptibility to their effects; shared environmental/lifestyle factors; interaction of genetic and environmental factors. Inherited defects in the clotting mechanism can also increase risk. Transient ischemic Attack attacks (TIAs) are "warning strokes" that produce stroke-like symptoms but no lasting damage. TIAs are strong predictors of stroke. A person who's had one or more TIAs is almost 10 times more likely to have a stroke than someone of the same age and sex who hasn't. African Americans have a much higher risk of death from a stroke than Caucasians do. This is partly Present or Absent Present Justification Patient has lived in the Philippines for a long period of time. Mr. Eks’ Mother told us during interview that she had a heart disease, CAD, and she also said that Mr. Eks’ father had stroke in the past.

Heredity

Present

Transcient Ischemic (TIA)

Present

Mr. Eks had his TIA on October 4, 2008

Race

Absent

Patient is a Filipino, and has lived in the Philippines his entire life so far.

because blacks have higher risks of high blood pressure, diabetes and obesity.

Precipitating Factors Factor Alcohol Use Rationale The exact pathogenic mechanism is unknown, but alcohol can contribute to high levels of triglycerides, produce cardiac arrhythmias, and cause heart failure Present or Absent Present Justification According to Mr. Eks’ wife he is a drinker. He drinks twice or thrice a week.

Smoking

Cigarette smoke Absent contains carbon monoxide and nicotine as well as numerous additional toxic compounds. Cigarette smoking has a role in promoting the atherosclerotic process particularly in the carotid arteries. (It is thought that carbon monoxide may play a role in damaging the arterial endothelium). Smoking also causes several changes in the blood. They include increased adhesiveness and clustering of platelets, shortened platelet survival, faster clotting time, and increased viscosity

According to Mr. Eks’ wife he does not smoke.

of the blood, which can affect flow velocity. Smokers have an increased risk of both ischemic and hemorrhagic stroke. Atrial Fibrilation Patients with atrial fibrillation have a greatly increased Present Upon gathering information from the chart, ECG shows an Atrial Fibrillation

risk of embolic strokes. Ineffective contraction of the atrium allows blood to pool along its walls and increases thrombus formation. Bits of these thrombi can travel through the left ventricle, enter the systemic circulation and embolize the brain. Post open heart Strokes occurring in Present surgery this situation are usually the result of surgically dislodged plaques from the aorta that travel through the bloodstream to the arteries in the neck and head, causing stroke. Cardiac surgery increases a person's risk of stroke by about 1 percent. Other types of surgery can also increase the risk of stroke. Heart Disease Any heart diseases Present may produce damage to the heart

When Mr. EKs’ was 17 years old he had an open heart surgery at Philippine Heart Center.

According to mother, Mr. Eks CHD that prompted

wall or persistent atrial fibrillation, both of which promote thrombus formation. Bits of thrombus may break off and embolize the brain. Diabetes Mellitus Diabetes increases Absent the risk of ischemic strokes through several interrelated mechanisms that favor (and accelerate) the formation of atherosclerotic plaque. In patients with diabetes, plaque is much more common in the smaller branches of cerebral arteries than in nondiabetics. The narrowing of these smaller vessels can directly increase the risk of stroke. High Level Cholesterol Concerning cerebrovascular disease specifically, what is known is that elevated total cholesterol and LDL is associated with increased degree and progression of carotid atherosclerosis, while elevated HDL levels have the opposite effect. Absent

Mr. Eks’ surgery and at present he has Rheumatic Heart disease.

Mr. Eks’ wife and his mother told us that he does not have diabetes mellitus.

Mr. Eks’ Laboratory showed he does nt have high Cholesterol level.

Hypertension

Vessels that are Present continuously subjected to high pressures are more likely to develop plaque, and it is more likely that the endothelial surface of the vessel will be damaged, promoting plaque rupture and the formation of thrombi. A thrombus can occlude the vessel locally or can break off and embolize the brain.

According to Mother, after Mr. Eks’ surgery he experiences most of the time unstable BP or Hypertension.

Symptomatology
Symptom Hemiparesis Rationale Present or Absent The resultant deficit Present is believed to be due to the large representation of the affected muscles in the homunculus. Blood clot from the Present CVA can prevent oxygen and nutrients from reaching nerve cells thus, resulting to cell death and the affected body cease to function. Cranial nerves 9 and Present 10 are located at the left hemisphere of the brain, which is the affected area, and aids in the eating process. Due to damage of Present the lateral gaze center Justification During our duty, we had observed weakness on his right side of the body. We have observed that Mr. Eks have slurred speech.

Aphasia

Dysphagia

Mr. Eks has an NGT for feeding purposes and upon gathering data, his chart showed negative gag reflex. Upon performing Neurovital signs, his right side of the body especially the upper and lower extremities cannot move.

hemiplegia

DOCTOR’S ORDER
DATE DOCTOR'S ORDER RATIONALE REMARKS

April 20, Pls. admit to ICU under the 2009 service of Dr. E. Durban BP=150/100 mmHg CR=60bpm RR= 18bpm O2 sat= 100% HGT= 5.2mmol/L Dr. Durban is out of town, to see patient, Dr. C.Fuentes Consent to care

The patient is in need of DONE medical attention so he is admitted in Ricardo Limso Hospital

To facilitate continuous care

DONE DONE

-For legal purposes -to know if the patient agrees on the terms of care of the hospital O2 inhalation at 4 LPM via breathing pattern is altered on nasal cannula patients having stroke NPO The patient is maintained on NPO in order to prevent aspiration and vomiting Monitor VS every hour Vital signs serves as the baseline data of the patient's entire stay in the hospital Monitor I & O every hour urinary incontinence is common in stroke patients Labs: These entire lab tests are 1. CBC performed to screen for 2. Urinalysis alteration and to serve as a 3. ECG baseline data for future 4. FBS comparison. 5. Serum Creatinine 6. Serum Sodium, Potassium, Calcium, Magnesium 7. Lipid Profile 8. SGPT 9. CXR- PA 10. HGT now Start Venoclysis with D5W500cc at KVO rate − To facilitate in giving IVTT medications

DONE DONE DONE DONE DONE

DONE

April 2009 3:00 pm ECGwith MVR Anterior wall myo ischemia Inc. RBBB Awake but aphasia Motor: move left extremities Grade 2/5 Left upper extremities 1/5 left lower extremities Right extremities=

Please insert NGT and Foley − For feeding purposes Catheter − to drain the patient’s urinary bladder since he is unable go to the comfort room Meds: 1. Pantoprazole (Partoloc) 40mg All medications previously IVTT now then 1 ampule O.D. ordered by attending 2. Citicoline ( Zynapse) 2 grams physician should be continued IVTT now then 1 gram IVTT to hasten patient's recovery. every 6 hours 3. Atorvastatin ( Lipitor) 80mg 2 tabs now/ NGT then 1 atb OD at HS/ NGT 4. Lanoxin0.25mg 1 tab OD Discontinue D5W500cc, shift to - For replacement of fluid PNSS 1L at 60cc/hour electrolytes balance maintenance. For cranial CT scan today CT scan provides detailed views of the body’s soft tissues, including blood vessels, muscle tissue, and organs, such as the brain. It is also used to determine any mass or obstruction present in the body 20, May accommodate to ROC For management and close monitoring of patient’s treatment. AF

DONE

DONE

DONE DONE

DONE

0/5 Monitor VS and NVS every Vital Signs and Neuro Vital DONE hour and record please. Signs serves as the baseline data of the patient's entire stay in the hospital Insert NGT to facilitate the feeding Start osteorized feeding at 50 ml for the patient to receive the every 3 hours x 7 feedings, then needed nutrients he needs flush with 25 ml water every because he is on NPO after O.F. Piracetam 1.2 grams IV x 30 All medications previously DONE minutes. Now then 3 grams ordered by attending every 6 hours physician should be continued to hasten patient's recovery. 5:30 pm Refer for any unusualities Referral is done to correct DONE CT scan unusualities as soon as result: possible and to inform the > nonattending physician of the hemorrhagic patient's condition. infarct with slight mass effect, left frontotemporal areas extending to the left basal ganglia 11:40 pm Decrease Atorvastatin to 80mg Atorvastatin is given to DONE ½ tab OD HS decrease blood cholesterol. The dosage is decreased since the patient’s blood cholesterol/LDL level has already decreased. Give pantoprazole P.O. 40 mg Pantoprazole is an anti- DONE OD secretory drug. April 21, Increase Osteorized Feeding to To meet the nutritional needs DONE 2009 100 ml every 3 hours then flush of the patient’s body. 4:55 am with 100cc water 1 PM Refer to Dra. Anuta for Neuro Referral is done to correct DONE Evaluation unusualities as soon as possible and to inform the attending physician of the patient's condition. Rounds with Dr. C. Fuentes For monitoring and DONE continuous care of the patient

April 2009 4:30 pm April 2009

April 2009 2:30 pm More Awake but still aphasia (-) BM

Mannitol is a diuretic and at DONE the same time decreases the blood pressure of the patient For replacement of fluid DONE electrolytes balance maintenance Increase osteorized feeding to To meet the nutritional needs DONE 150ml every 3 hours then flush of the patient’s body. with 150ml water 21, IVF to follow as PLR 1L at For replacement of fluid DONE 80cc/ Hour electrolytes balance maintenance. 22, Lactulose 40ml now then 30 ml Since the patient is unable to DONE OD HS defecate, lactulose is given to aid in defecation. 22, Repeat urinalysis For further evaluation DONE

Start Mannitol 200ml IV for 30 minutes now, then 160cc every 4 hours to run for 30 minutes IVF to follow with PLR 1L at 60cc/ hour

April 2009

To stimulate his neurologic function For replacement of fluid electrolytes balance maintenance. 22, Decrease Mannitol to 120 ml Mannitol is a diuretic and at every 4 hours IV x 30 mins the same time decreases the blood pressure of the patient Increase O.F. to 200ml every 3 To meet the nutritional needs hours then flush with 200ml of the patient’s body. water every after O.F.

Neurology: - Thank you very much for their referral - Impression: Large infarct, Left MCAD - Suggestion/ Comment 1. Curative manifestation = may start to transfer on 5 days 2. Curative Citicoline IV 3. Suggest 2 D Echo if not yet done 4. Suggest Rehab; referral Suggest to instruct watchers to keep on talking to patient IVF to follow with PLR 1L at 80cc/hour

This is for the collaborative DONE health care of the patient. Assessment of the patient is endorsed for the continuity of care.

DONE DONE DONE DONE

April 2009 4:40 pm 9 pm April 2009 6:15 am

22, Refer to Dra. Santos for P.T. Repeat serum electrolytes( Na+, K+) from AM, to include from protime with INR 23, Shift IV Piracetam to 1.2 g/ tab 1 tab BID Rehabilitation Medicine: - Thank you for your kind referral - seen and examine patient; chart entries renewed - will put him on a post stroke rehab program - kindly secure 3 PT sessions IVF to follow PLR 1L at 80cc/ hour To follow PLR IV at 80cc/ hour Decrease Mannitol drugs to 100ml every 4 hours x 30 minutes 23, IVF to follow as PLR 1L at 80cc/hr

For monitoring and DONE continuous care of the patient To evaluate the efficiency of DONE serum electrolytes and to see if there are any complications. Piracetam is used to improve DONE memory process For further evaluation and for DONE motor training.

April 2009 April 2009 2:20pm

April 2009 10:30 am

23, Increase O.F. to 250ml then DONE flush with water 200ml every after O.F. I’ll be out of town today until To inform and be aware the DONE April 26, 2009 medical services done with the patient. 24, Please inform Dr. Santos To have further evaluation. DONE Decrease citicoline to 1 gram Improvement of speech was DONE every 8hrs. IV noted so Citicoline was decreased. Rehabilitation Medicine: For further evaluation and for DONE -latest serum electrolytes noted motor training. - for initiation of rehab session still PLR at 80cc/hr For replacement of fluid DONE

For replacement of fluid electrolytes balance maintenance. For replacement of fluid electrolytes balance maintenance. Mannitol is a diuretic and at the same time decreases the blood pressure of the patient For replacement of fluid electrolytes balance maintenance. To meet the nutritional needs of the patient’s body.

DONE DONE DONE DONE

electrolytes balance maintenance. Rehabilitation medicine For further evaluation and for DONE nd -tolerated 2 session of rehab motor training. family well with stable VS and NVS today - will continue rehab program on Monday PLR 1L at 80cc/hr For replacement of fluid DONE electrolytes balance maintenance. April 24, Replace foley catheter and Indwelling catheters should be DONE 2009 urobag replaced every 3 days since (+) on- follow there is always that risk for (+) active infection. movement Left UE/LE (-) Homan’s sign Still unable to protrude fingers For urinalysis (please use For further evaluation DONE aseptic technique) April 25, Alprazolam 250mg 1 tab/ NGT For short term relief of DONE 2009 anxiety Mupirocin (Bactroban) TID to For treatment of blisters DONE affected areas April 26, Sultamicillin ( Unasyn) 750mg For treatment of infections DONE 2009 tab, 1 tab, PO 4:15 pm Turn to sides every 2 hours To prevent bed sores DONE Alprazolam 250mg tab; 1 tab For short term relief of DONE every 12 hours PRN for anxiety persistent hiccups April 26, For 2D echo To examine the working heart DONE 2009 and to display moving images 9:45 pm of its action. Decrease Mannitol 60cc every 4 Mannitol is a diuretic and at DONE hours the same time decreases the blood pressure of the patient Endorsing patient back to rehab For monitoring and DONE continuous care of the patient Start Imdur 60 mg tab; ½ tab at For acute angina attacks DONE HS Review of meds: All medications previously DONE

April 2009 1:30 pm

For replacement of fluid DONE electrolytes balance maintenance. Vandol ointment, apply TID to To treat diaper rash DONE diaper rash, after cleaning area April 27, Rehabilitation medicine: For further evaluation and for DONE 2009 - cardiac findings (2D ECHO) motor training. 5:20 pm notedcardiac precautions Still unable to observed during rehabilitations protrude - kindly secure 2 OT sessions fingers for pre- finding and pre- speech training SALAMAT PO April 28, IVF to follow PLR 1L at For replacement of fluid DONE 2009 80cc/hr electrolytes balance 1:30 pm maintenance. Remove urinary catheter Condom catheter is inserted DONE change to condom catheter since patient is now able to void freely.

1. Citicoline tab 500mg 2 tabs every 12 hours 2. Imdur 60 mg ½ tab at HS 3. Mannitol 60cc every 4 hours 4. Lactulose 30cc at HS 5. Piracetam 1.2gms., 1 tab BID 6. Alprazolam 250mg 1 tab every 12 hours PRN for Hiccups 7. Lanoxin 1 tab OD 8. Pantoprazole 40mg 1 tab OD at HS 10. Unasyn 750mg 1 tab BID 11. Bactroban apply TID to affected areas 27, Start bladder training, clamp catheter release for 30 minutes every 4 hours Rehabilitation Medicine: >Kindly secure another 3 PT session please > For oral hygiene with bactidol BID please and also provide watcher with OS covered/ padded tongue depressor > Paracetamol 500mg 1 tab now then every 4 hours for fever #13 IVF with PLR 1L to run at 80cc/hr

ordered by attending physician should be continued to hasten patient's recovery.

In preparation for the removal DONE of foley catheter. PT sessions enhance motor DONE skills to have a faster recovery. Oral hygiene is to prevent further infection from the respiratory tract. Paracetamol relieves fever.

April 2009 7:50 am 10:30 am

Lactulose Drug is discontinued since DONE patient is now able to defecate. Nebulize with Ambroxol/ A bronchodilator and DONE Bisolvon + NSS TID mucolytic which aids in the removal of phlegm. 29, Chest tapping after each For faster removal of DONE nebulization secretions/phlegm. May give gelatine cubes PRN per orem, Watch out for aspiration Repeat CBC today Nebulize with ambroxol for inhalation 10gtts + PNSS 2ml TID Rehabilitation medicine: -for continuation of PT and OT sessions today May have sips of gelatine with SAP Consume and discontinue IVF To exercise the patient’s DONE mastication process For further evaluation. DONE To aid in the removal of DONE phlegm To work-out the patient’s DONE motor and verbalization skills. To prevent from aspiration. DONE

Discontinue temporarily

7:01 pm Febrile Increase WBC 11.06 For WBC 9 April 30, Remove NGT after 2009 feeding tomorrow April 2009 3:20pm

All meds were ordered orally. DONE No more IVTT meds.

am To prevent Mr. Eks’ to DONE become independent from using NGT when eating. 30, May have general liquids Since Mr. Eks’ NGT will be DONE ( including O.F) to very soft diet removed, general liquids was thereafter STRICT ordered to slowly introduce ASPIRATION PRECAUTION foods into the body through the mouth.

6

DIAGNOSTIC EXAM

ECHOCARDIOGRAPHY AND COLOR FLOW DOPPLER Date: April 27, 2009 QUANTITATIVE Dimension Patient Normal Function Patient Normal LV (ed) 5.4 4.5-5 LVEDV 140.1 LV (es) 2.9 LVESV 33.3 RV (ed) 3.6 2.2-4 STROKE 106.8 VOL LA (es) 4.5 3-3.5 CO 7.3 RA (es) 4.2 3.5-4.5 CI AORTA 3.4 3.5 EF % 76 55-77 PA 3.2 3-4 FS % 45 2.2-4 IVS (ed) 1.4 .8-1.1 VCF .8-1.5 (CIR)/SE IVS (es) 1.8 EPSS 0.9 <=1 WALL LVPW (ed) 1.25 0.8-1.1 < 195 LVPW (es) MV ANNU TV ANNU LVET 1.8 4.7 3.9
STRESS WALL STRESS

< 600 1.0 69 AF

LV WMSI HEART RATE RHYTHM

SPECTRAL AND COLOR FLOW DOPPLER VALVE MX VEL (m/s) PEAK GRAD mmHg Aortic 1.4 2.0 7.5 17.0 Mitral 2.3 20.6 Tricuspid 0.5 1.2 Pulmonic 0.8 2.8 Pat = 122 INTERPRETATION: Rheumatic Heart Disease, several mitral stenosis with mitral valve area of 0.8 cm² by pressure half time and 0.9 cm² by planimetry, peak gradient of 20.6 mmHg. The anterior mitral valve leaflet is thickened with calcifications at the margins. The posterior mitral valve leaflet is fixed. There is restriction of motion of both leaflets with anterior doming motion of the anterior mitral valve leaflet during diastole. Both commissures are fused. The subvalvar apparatus is thickened. Wilkin’s score of 8 (subvalvar apparatus – 2, mobility – 2, calcifications – 2, thickening - 2). Structurally, normal tricuspid, aortic and pulmonic valves with good opening and closing motion.

Dilated left ventricle with concentrically hypertrophied walls. There is adequate wall motion and contractility. Slightly dilated right ventricle with adequate wall motion and contractility. Dilated right and left arterial sizes without evidence of thrombus Normal aortic root. Normal main pulmonary artery and pulmonary artery systolic pressure. No pericardial effusion. DOPPLER STUDY: Mild mitral, tricuspid and aortic regurgitations. Trivial pulmonic regurgitation. CONCLUSION: Rheumatic Heart Disease, severe mitral stenosis with mitral valve area of 0.9 cm², peak gradient of 20.6 mmHg. Wilkin’s score of 8. Eccentric left ventricular hypertrophy with preserved overall resting systolic function. Dilated right ventricle with adequate wall motion and contractility. Dilated left and right arterial sizes without evidence of thrombus. Mild mitral, tricuspid, and aortic regurgitations. Trivial pulmonic regurgitation.

RADIOLOGY

Clinical Impression: Body Malaise Part examined: Chest FINDINGS: There is no definite radiographic evidence of active pulmonary infiltrate. Vascular shadows however appear engorged. Cardiac shadow appears enlarged with laterally displaced apex and convex left atrial border. Sternotomy wires are appreciated. Diaphragm and costophrenic sulci are intact. No other significant findings. IMPRESSION: Cardiomegaly is considered left sided predominance with pulmonary congestion.

CRANIAL CT SCAN FINDINGS: Multiple plain axial tomographic sections of the head were obtained. Low attenuation density changes are noted in the left fronto-temporal areas extending into the left basal ganglia. No external axial fluid collection noted. The frontal horn of the left lateral ventricle is compressed with slight midline shift to the right. The rest of the ventricles are unremarkable. The sulci and cisterns are slightly compressed on the affected side. The posterior fossa, sella, orbits, paranasal sinuses, and petromastoids are unremarkable. IMPRESSION: Non hemorrhagic infarct with slight mass effect, left frontotemporal areas extending into the left basal ganglia.

HEMATOLOGY

Date: April 29, 2009 Parameter Hemoglobin - To identify the amount of oxygen carrying protein contained within the RBC. Hematocrit -to identify the percentage of the blood volume occupied by red blood cells. -decreased HCT indicates blood loss, anemia, blood replacement therapy, and fluid balance, and screens red blood cells status RBC -to know the amount of RBC in the blood. -a decreased count may indicate anemia, fluid overload, or severe bleeding WBC -to determine infection or inflammation in the body and monitor its responses to specific therapies. -a leukocyte count is elevated in infectious diseases of the heart (e.g., acute bacterial endocarditis) -increases because large number of white cells are necessary to dispose of the necrotic tissue resulting from the infarction. Neutrophil -active phagocytes; number increases rapidly during short-term or acute infections. - increases in localized tissue death 0.80 0.55 0.65 11.60 10 ˆ 9/L 5 10 4.86 10ˆ 12/L 5.5 6.5 0.45 0.40 0.54 Results 153 Units g/L Lower limits 135 Upper limits 180

(ischemia) due to heart attack, burns, carcinoma. Lymphocyte -part of immune system; one group (B lymphocytes) produces antibodies; other group (T lymphocytes) involved in graft rejection, fighting tumors and viruses, and activating B lymphocytes - decreased by severe debilitating illness such as heart failure, renal failure, and advanced TB Monocyte -active phagocytes that become macrophages in the tissues; long-term “clean-up team” -an increase may respond to corticosteroid, with pus conditions, hemorrhage. Eosinophil -kills parasitic worms; might pathocyte antigen-antibody complexes and inactive inflammatory chemicals. Basophil granules contain histamine (vasodilator chemical), which is discharged at sites of inflammation Platelet count -is the number of platelets in a given volume of blood. -responsible for beginning the process of coagulation, or forming a clot, whenever a blood vessel is broken -both increase and decrease can point to abnormal conditions of excess bleeding or clotting.

0.09

0.25

0.35

0.09

0.03

0.06

0.02

0.02

0.04

0.00

0

0.01

129

150

350

Date: April 20, 2009

Parameter Hemoglobin Hematocrit RBC WBC Neutrophil Lymphocyte Monocyte Eosinophil Basophil Platelet count

Results 164 0.47 5.20 9.27 0.68 0.18 0.10 0.04 0.00 148

Units g/L 10ˆ 12/L 10 ˆ 9/L

Lower limits 135 0.40 5.5 5 0.55 0.25 0.03 0.02 0 150

Upper limits 180 0.54 6.5 10 0.65 0.35 0.06 0.04 0.01 350

PROTIME Date: April 24, 2009 Result: Control: 13,1 s Pts. Value: 13, 3 s INR: 1, 16 s Ref. range: 0.87-1.11 2-2.5 = prophylaxis if deep vein thrombosis including high risk surgery 2-3 = hip surgery and operation for fractured femur 2-3 = treatment of deep vein thrombosis, pulmonary embolism and transcient ischemic attack 2-4 = recurrent deep vein thrombosis, pulmonary embolism, arterial disease including myocardial infarction, arterial grafts, cardiac prosthetic valves and grafts.

URINALYSIS

Date: April 26, 2009 Physical: Color: bloody Appearance: cloudy Macroscopic Chemical: specific Gravity: 1.030 Reaction (pH): acidic (5.0) Microscopic

Albumin: ++++ (4 plus) Sugar: negative

Cells: Pus cells: NUM/Hpf Erythrocytes/RBC: NUM/Hpf

Date: April 22, 2009 @ 3:58 pm Macroscopic Chemical: specific Gravity: 1.010 Reaction (pH): acidic (6.0) Microscopic

Physical: Color: yellow Appearance: slightly cloudy

Albumin: trace Sugar: negative

Cells: Pus cells: 1-5/Hpf Erythrocytes/RBC: 15-30/Hpf

Date: April 22, 2009 @ 11:59 am Physical: Color: yellow Appearance: slightly cloudy Macroscopic Chemical: specific Gravity: 1.010 Reaction (pH): 6 Microscopic Cells: Pus cells: 1-5/Hpf Erythrocytes/RBC: 15-30/Hpf Squamous: ++ (2 plus) Bacteria: few Mucus threads: few CLINICAL CHEMISTRY

Albumin: trace Sugar: negative

Date: April 24, 2009 @ 11: 59 am Test Soduim, substc Potassium, substc Result 135. 2 3,69 Ref. range 135-148 3,5-5,3 SI units mmol/L mmol/L

Date: April 21, 2009 @ 11:08 am Test Glucose, substc SGPT, Activity C. Cholesterol ADL LDL Urate, substc Triglycerides Result 4.88 56, 11 3, 52 0, 77 2, 41 0, 27 0, 75 Ref. range 3, 89-5, 83 M: 0-41 Up to 5,2 More than 0, 91 Less than 3,5 M: 0, 21 – 0, 42 Up to 1,7 SI units mmol/L u/L mmol/L mmol/L mmol/L mmol/L mmol/L

Date: April 20, 2009 @ 9:15 pm Test K+, substc Ca+, substc SGPT, activity C Crea, substc Na+, substc Mg Result 3.62 1.15 56.00 66, 21 146 0, 30 Ref. range 3,5-5,3 1,13-1,32 M: 0-41 M: <50 y.o.: less than 115 >50 y.o.: less than 124 135-148 0,7 – 0, 98

Generic Name: Digoxin Brand Name: Lanoxin

Classification Pharmacologic: cardiac glycoside

Dose 1 tab, O.D., 0.25 mg

Mode of action Inhibits

Indication

Contraindications

sodium- Heart failure, paroxysmal

Drug interactions 1. Contraindicated Amiloride: may in patients decrease digoxin to effect and

Side effects CNS: agitation, fatigue, generalized muscle weakness,

Nursing responsibilities 1.Before giving drug, take apicalradial pulse for 1 minute. Record and notify physician of any

potassium-activated adenosine triphosphatase,

supraventricular hypersensitive tachycardia,

drug and in those increase digoxin with induced ventricular fibrillation, digitalis- excretion. toxicity, Amiodarone, diltiazem, or indomethacin, nifedipine,

Inotropics

promoting movement atrial of calcium from fibrillation and to flutter

extracellular intracellular cytoplasm strengthening myocardial

hallucinations, changes (sudden dizziness, headache, stupor, vertigo. CV: arrhythmias, increase or decrease in pulse rate, pulse deficit, irregular beats, and regularization of a previously

and

ventricular

tachycardia unless quinidine, caused failure. 2. Use by heart verapamil: may increase digoxin with level.

contraction. Also acts on CNS to enhance

vagal tone, slowing conduction through

extreme caution in Amphotericin B, patients with acute carbenicilin, MI, incomplete corticosteroids,

heart block. EENT:

irregular rhythm). 2.Toxic effects on

the SA and AV nodes

blurred vision, the heart may be diplopia, light flashes, photophobia, yellow-green halos around visual images. GI: anorexia, nausea, diarrhea, vomiting. life-threatening and require immediate attention. 3.Monitor digoxin and potassium level. 4.Teach responsible family member about drug action, dosage regimen, how to take pulse, reportable signs,

AV block, sinus diuretics, bradycardia, PVCs, constrictive pericarditis, hypertrophic cardiomyopathy, ticarcillin: may

chronic cause hypokalemia, predisposing client to toxicity. Antacids: may

renal insufficiency, decrease severe pulmonary absorption of oral disease, hypothyroidism. or digoxin. Antibiotics, propafenone, ritonavir: may increase risk of

toxicity. Anticholinergics: may increase absorption of digoxin tablets. Beta-blockers, calcium-channel blockers: may have additive effects on AV node conduction causing advanced or complete heart block. Cholestyramine, colestipol, metoclopramide:

and follow-up care. 5.Inform to report pulse less than 60 beats/minute or more than 110 beats per minute, or skipped beats or other rhythm changes. 6. Instruct to report adverse reaction immediately.

may decrease absorption of oral digoxin. Give digoxin 1 ½ hours before or 2 hours after other drugs. Parenteral calcium, thiazides: may cause hypercalcemia and hypomagnesemia. Generic Name: Levofloxacin Brand Name: Levaquin

Classification Pharmacologic class.: fluoroquinolone

Dose 1 tab, O.D., 500 mg

Mode of action Inhibits

Indication - mild to

Contraindications 1.Contraindicated in

Drug interactions Antidiabetics:

Side effects CNS: encephalopathy, seizures, dizziness, headache, insomnia, pain, paresthesia. CV: chest pain, palpitations, vasodilation. GI:

Nursing responsibilities 1.Administer drug as prescribed even if signs and symptoms disappear. 2.Advise to take drug with plenty of fluids. 3.Instruct to avoid activities that require alertness. 4.Instruct to stop drug

bacterial DNA moderate skin gyrase and and skin

patients may alter to glucose level. its Iron salts: may or decrease absorption of levofloxacin,

hypersensitive drug, components, other fluoroquinolones.

prevents DNA structure replication, transcription, repair, and infections

recombination in susceptible bacteria.

2.Use cautiously in reducing antipatients with infective

history of seizure response. disorders or other NSAIDS: may CNS disorders. increase CNS stimulation. Monitor for

pseudomembranous and notify prescriber if colitis, abdominal pain, constipation, rash or other signs and symptoms of

diarrhea, dyspepsia, hypersensitivity

seizure activity. flatulence, nausea Warfarin and derivates: may increase effect of oral anticoagulant. and vomiting. Hematologic: lymphopenia, eosinophilia, hemolytic anemia.

develop. 5.Inform that drug may cause abnormal ECG.

Monitor PT and Metabolic: INR. hypoglycemia. Musculoskeletal: back pain, tendon rupture. Respiratory: allergic pneumonitis Skin: erythema multiforme, photosensitivity,

pruritus, rash. Other: anaphylaxis, multisystem organ failure, hypersensitivity reactions.

Generic Name: Citicoline Brand Name: Cholinerv Classification Dosag e Mode of Action Indication/s Contraindicatio n Drug-drug Interaction Adverse Reaction Nsg. Responsibilties

Neuroprotective 500mg ; CNS Drugs & 2 tabs Agents for ADHD

- Citicoline is an interneuronal communication enhancer. It increases the neurotransmissio n levels because it favors the synthesis and production speed of dopamine in the striatum, acting then as a dopaminergic agonist thru the inhibition of tyrosinehydroxylase.

CVD in acute Parasympatheti & recovery c hypertonia phase, symptoms & signs of cerebral insufficiency (dizziness, memory loss, poor concentration , disorientation , recent cranial trauma & their sequelae.)

Somazine potentiates the effects of Ldopa. Incompatibilities : Somazine must not be administered with products containing meclofenoxate (clophenoxate)

Gastrointestina l disorders. Allergic reaction: Itching or hives, swelling in your face or hands, swelling or tingling in your mouth or throat, chest tightness, trouble breathing, or rash, Low blood pressure (faintness, dizziness), Slow or fast heart beat, Headache, Nausea, vomiting, or diarrhea (loose BMs)

•Somazine must not be administered along with medicaments containing meclophenoxat e

Generic Name: Alprazolam Brand Name: Niravam, Xanax

Classification

Dosage 250mg 1 tab every 12 hours PRN

Mode of Action Exact mechanisms of action not understood; main sites of action may be the limbic system and reticular formation; increases the effects of gammaaminobutyrate, an inhibitory neurotransmitter; anxiety blocking effects occur at doses well below those necessary to cause sedation, ataxia.

Indication/s Management of anxiety disorders, short-term relief of symptoms of anxiety; anxiety associated with depression. - Treatment of panic attacks with or without agoraphobia. - Unlabeled uses: Social phobia, premenstrual syndrome, depression

Contraindication

Drug-drug Interaction -Contraindicated - Increased with CNS depression hypersensitivity with alcohol, to other CNS benzodiazepines, depressants, psychoses, acute propoxyphene narrow-angle - Increased glaucoma, effect with shock, coma, cimetidine, acute alcoholic disulfiram, intoxication with omeprazole, depression of isoniazid, vital signs, hormonal pregnancy contraceptives, (crosses the valproic acid placenta; risk of - Decreased congenital effect with malformations, carbamazepine, neonatal rifampin, withdrawal theophylline syndrome), labor - Possible and delivery increased risk ("floppy infant" of digitalis syndrome), toxicity with lactation digoxin (secreted in - Decreased breast milk; antiparkinson infants become effectiveness of lethargic and levodopa with lose weight). benzodiazepines - Use cautiously Contraindicated

Adverse Reaction - CNS: Transient, mild drowsiness initially; sedation, depression, lethargy, apathy, fatigue, lightheadedness, disorientation, anger, hostility, episodes of mania and hypomania, restlessness, confusion, crying, delirium, headache, slurred speech, dysarthria, stupor, rigidity, tremor, dystonia, vertigo, euphoria,

Nsg. Responsibilties Take this drug exactly as prescribed; take extendedrelease form once daily in the AM. • Do not drink grapefruit juice while on this drug. • Do not stop taking drug (long-term therapy) without consulting health care provider. • Avoid alcohol, sleep-inducing, or over-thecounter drugs. • These side effects may occur: Drowsiness,

with impaired liver or kidney function, debilitation.

with ketoconazole, itraconazole; serious toxicity can occur

nervousness, difficulty in concentration, vivid dreams, psychomotor retardation, extrapyramidal symptoms; mild paradoxical excitatory reactions during first 2 weeks of treatment -CV: Bradycardia, tachycardia, cardiovascular collapse, hypertension, hypotension, palpitations, edema Dermatologic: Urticaria, pruritus, rash, dermatitis -EENT: Visual and auditory disturbances,

dizziness (less pronounced after a few days, avoid driving a car or engaging in other dangerous activities if these occur); GI upset (take drug with food); fatigue; depression; dreams; crying; nervousness. • Report severe dizziness, weakness, drowsiness that persists, rash or skin lesions, difficulty voiding, palpitations, swelling in the extremities.

diplopia, nystagmus, depressed hearing, nasal congestion -GI: Constipation, diarrhea, dry mouth, salivation, nausea, anorexia, vomiting, difficulty in swallowing, gastric disorders, hepatic dysfunction

Generic Name: Pantoprazole

Brand Name: Protonix Classification Antisecretory agent; Proton pump inhibitor Dosage 40 mg 1 tab OD Mode of Action Gastric acidpump inhibitor: Suppresses gastric acid secretion by specific inhibition of the hydrogenpotassium ATPase enzyme system at the secretory surface of the gastric parietal cells; blocks the final step of acid production. Indication/s Contraindication Drug-drug Interaction Oral: ShortContraindicated Decreased term (< with absorption of 8 wk) and hypersensitivity ketoconazole and long-term to any proton itraconazole; may treatment of pump inhibitor slightly increase GERD or any drug digoxin plasma (gastric components. concentration; may esophageal • reduce plasma reflux disease) Use cautiously concentration of • with pregnancy, atazanavir, avoid IV: Short-term lactation concomitant use; (7–10 days) may enhance treatment of anticoagulant GERD in effect of patients coumarins; may unable to cause gastric continue oral mucosal irritation therapy with alcohol; may • increase levels or Treatment of effects of: pathological bosentan, dapsone, hypersecretory fluoxetine, conditions glimepiride, associated glipizide, losartan, with montelukast, Zollingernateglinide, Ellison paclitaxel, syndrome and phenytoin, other warfarin, and Adverse Reaction CNS: Headache, dizziness, asthenia, vertigo, insomnia, apathy, anxiety, paresthesias, dream abnormalities • Dermatologic: Rash, inflammation, urticaria, pruritus, alopecia, dry skin • GI: Diarrhea, abdominal pain, nausea, vomiting, constipation, dry mouth, tongue atrophy Nsg. Responsibilties -Instruct patient to take medication as directed for the full course of therapy, even if feeling better. -Advise patient to avoid alcohol, products containing aspirin or NSAIDs, and foods that may cause an increase in GI irritation, -Advise patient to report onset of black, tarry stools; diarrhea; or abdominal pain to health care professional promptly. -Administer

neoplastic conditions • Unlabeled uses: Treatment of peptic ulcer

zafirlukast; may decrease levels or effects of: aminoglutethimide, carbamazepine, phenytoin, and rifampicin.

• Respiratory: URI symptoms, cough, epistaxis • Other: Cancer in preclinical studies, back pain, fever

once or twice a day. Caution patient to swallow tablets whole; not to cut, chew, or crush them. -Arrange for further evaluation of patient after 4 wk of therapy for gastroreflux disorders. Symptomatic improvement does not rule out gastric cancer; gastric cancer did occur in preclinical studies. -Maintain supportive treatment as appropriate for underlying problem. -Switch patients on IV therapy to oral

dosage as soon as possible. -Provide additional comfort measures to alleviate discomfort from GI effects and headache.

Generic Name: Chlorpromazine Brand Name: Largactil Classificatio n Dosag e Mode of Action Chlorpromazi ne is an aliphatic phenothiazine. Phenothiazine s are thought to elicit their antipsychotic and antiemetic effects via interference with central dopaminergic pathways in the mesolimbic and medullary chemoreceptor trigger zone areas of the brain, respectively. Indication/s Psychotic disorders, N/V*, apprehensio n, intractable hiccups Contraindicati on Crosssensitivity w/ phenothiazines; NAG Drug-drug Interaction ↑Effects W/amodiaquine,chloroqui ne, sulfadoxine– pyrimethamine, antidepressants, narcotic analgesics,propranolol, quinidine, BBs, MAOIs, TCAs, EtOH, kava kava; ↑effects OFanticholinergics, centrally acting antihypertensives, propranolol, valproic acid; ↓ef-fectsW/antacids, antidiarrheals, barbiturates, Li, tobacco; ↓effects OFanticonvulsants, guanethidine, levodopa, Li, warfarin. Adverse Reaction These include sedation, dry mouth, constipation , urinary retention, possible lowering of seizure threshold, uncontrollable movements of the tongue, face, lips, arms, or legs, muscle spasms of the face or neck, and severe restlessness or tremor. Appetite may be increased with resultant weight gain, Glucose tolerance Nsg. Responsibiltie s Take drug exactly as ordered. • Meds take 6 wks or longer to achieve full clinical effect. • WBC monitored for 3 months. (WOF signs of infection) • Avoid driving & operating machineries. • Avoid direct sunlight. • Avoid extremes in temperatures & increased exercise.

Antipsychoti 100m c g¼ tab every 6 hours

may be impaired.

• Change positions Photosensitivit slowly. y may occur, • resulting in Alipathic increased risk phenothiazine of sunburn. s  pink-red brown urine. • Suggest lozenges, hard candy for dry mouth. • Changes to sexual functioning & menstruation.

Generic Name: Paracetamol Brand Name: Aeknil Classification Anti-pyretic; analgesic Dosage 500mg, 1 tab PRN Mode of Action Indication/s Contraindication Drug-drug Interaction Contraindicated Anticoagulant in patients drugs (warfarin) hypersensitive - dosage may to drug. require -Use cautiously reduction if in patients with paracetamol and long term anticoagulants alcohol use are taken for a because prolonged therapeutic period of time doses cause • hepatotoxicity Paracetamol in these patients. absorption is -Hematologic: increased by hemolytic substances that anemia, increase gastric neutropenia, emptying, e.g. leucopenia, metoclopramide pancytopenia. • -Hepatic: Paracetamol Jaundice absorption is -Metabolic: decreased by Hypoglycemia substances that -Skin: rash, decrease gastric urticaria. emptying, e.g. propantheline, antidepressants with Adverse Reaction When taken at the recommended dose, sideeffects of paracetamol are rare. Skin rashes, blood disorders and a swollen pancreas have occasionally happened in people taking the drug on a regular basis for a long time. One advantage of paracetamol over aspirin and similar drugs (eg ibuprofen and diclofenac) is that it won't upset your stomach or Nsg. Responsibilties • Use liquid form for children and patients who have difficulty swallowing. • In children, don’t exceed five doses in 24 hours. • Advise patient that drug is only for short term use and to consult the physician if giving to children for longer than 5 days or adults for longer than 10 days. • Advise patient or caregiver that many over

Paracetamol Mild pain; reduces fever and Fever relieves the muscular pain characteristic of influenza. This is a nontoxic drug that has excellent gastric tolerance and is increasingly accepted and used.Phenylephrine reduces congestion, edema and secretions that cause nasal obstruction, and provides a bronchodilatory effect without increasing cardiac rate. Carbetapentane fights against cough, and vitamins B1 and C aid in strengthening

organic defense mechanisms.

anticholinergic properties, and narcotic analgesics • Paracetamol may increase chloramphenicol concentrations • The risk of paracetamol toxicity may be increased in patients receiving other potentially hepatotoxic drugs or drugs that induce liver microsomal enzymes such as alcohol and anticonvulsant agents • Paracetamol excretion may be affected and plasma concentrations altered when given with

cause it to bleed.A paracetamol overdose is particularly dangerous because the liver damage may not be obvious for four to six days after the drug has been taken. Even if someone who has taken a paracetamol overdose seems fine and doesn't have any symptoms, it's essential that they are taken to hospital urgently. An overdose of paracetamol can be fatal.

the counter products contain acetaminophen; be aware of this when calculating total dailydose. • Warn patient that high doses or unsupervised long term use can cause liver damage.

probenecid • Colestyramine reduces the absorption of paracetamol if given within 1 hour of paracetamol.

Generic Name: Isosorbide mononitrate Brand Name: Imdur

Classification Nitrates

Suggested Mode of Dose Action 60 mg tab; -Thought to ½ tab at reduce HS cardiac oxygen demand by decreasing preload and afterload. - Drugs may also increase blood flow through the coronary vessels.

Indication Acute Anginal Attacks: to prevent situations that amy cause angina attacks

Contraindication - Contraindicated in patients with hypersensitivity or idiosyncrasy to nitrates and in those with severe hypotension, angle- closure glaucoma, icreased ICP, shock, or acute MI with low left ventricular filling pressure. - use cautiously in patients with blood volume depletion or mild hypertension

Drug Interactions Antihypertensiv e: may increase hypotensive effects

Adverse Effects CNS: headache, dizziness, weakness CV: orthostatic Hypotension, tachycardia, palpitations, ankle edema, flushing, fainting EENT: burning GI: nausea and vomiting Skin: cutaneous vasodilation, rash

Nursing Responsibilities
-

-

-

-

-

-

Monitor blood pressure and intensity and duration of drug response Drug may cause headache, especially at the beginning of the therapy. Dosage may be reduced temporarily, but tolerance usually develops. Treat headache with Aspirin or Acetaminophen Caution patient to take drug regularly as prescribed, and to keep it accessible at all times. Advise patient that stopping drug abruptly may cause spasm of the coronary arteries with increased abgina symptoms and potential risk of heart attack. Caution patient to avoid alcohol because it may worsen low blood pressure effects. Warn patient not to confuse S.L.

Brand Name: Vandol ointment

Classification Emollient

Suggested Dose TID on affected areas

Mode of Action Used to rehydrate and thus soothe the skin. Their use is valuable in all conditions characterize d by dryness, scaling and cracking of the skin.

Indication Soothes pain and helps healing of minor wounds and burns, protects skin from diaper rash.

Contraindication Preparations containing corticosteroids are generally contraindicated

Drug Interactions The topical application of zinc- or calaminecontaining emollients may further promote healing.

Adverse Effects Most emollients can be used safely and effectively with no side effects. However, if redness, irritation or itching occur or continue, notify your doctor or pharmacist. Inform your doctor if the condition for which this medication was prescribed does not improve after a few days. If you notice other effects not listed above, contact your doctor or pharmacist.

Nursing Responsibilities - Frequent application is usually needed and continued prophylactic use is usually recommended even after initial improvement occurs. - Excessive drying and defatting of the skin should be avoided, e.g. hot baths, alcoholic skin preparations, detergents, alkaline soaps, etc. - Urea and other moisturising agents (humectants) are incorporated into several emollient creams and lotions. Such preparations may be useful in the dry and scaly eczemas as well as in psoriasis. - Camphor, menthol and phenol are mildly antipruritic additives of certain emollients. - Some ingredients may cause hypersensitivity reactions - most notably lanolin, certain preservatives, fragrances and antibacterials.

Generic Name: Brand Name: Classificat ions

Sultamicillin Unasyn

Suggested Dose

Mode of Actions

Indications

Contraindications

Drug Interactions

Side Effects/ Adverse Reactions

Nursing Responsibilities

Antibiotic

750mg tab; 1 tab, PO

Sulbactam blocks the enzyme which

Upper & lower resp tract infections eg

History of allergic reaction to any penicillins.

Drug-drug. -Allopurinol: The concurrent administration of allopurinol and ampicillin increases substantially the incidence of rashes in patients receiving both drugs as compared to patients receiving ampicillin alone. -Anticoagulants: Penicillins can produce alterations in platelet aggregation and coagulation tests. These effects may be additive with anticoagulants.

-Allergic reaction,

1. Instruct patient on proper use of the

breaks down sinusitis, ampicillin otitis media, and thereby tonsillitis, aallows bacterial ampicillin to pneumonias, attack and bronchitis, kill the bacteria. UTI, pyelonephriti s, skin & soft tissue infections & gonococcal infections. Oral followup therapy to Unasyn IM/IV.

anaphylactoid drug reaction and 2. Urge patient to anaphylactic avoid cigarette shock. smoking because -Dizziness this may increase gastric acid diarrhea/loose secretion and stools, nausea, worsen disease Epigastric 3. Inform patient to distress, vomiting, melena and abdominal pain/cramps -Dyspnea -Rash and take drug once daily prescription at bedtime for best results. 4. Tell the physician what medicines you are taking, including those bought without a prescription and

itching -Bacteriostatic Drugs (chloramphenicol, Drowsiness/se erythromycin, dation, sulfonamides and

tetracyclines): Bacteriostatic drugs may interfere with the bactericidal effect of penicillins; it is best to avoid concurrent therapy. -Methotrexate: Concurrent use with penicillins has resulted in decreased clearance of methotrexate and a corresponding increase in methotrexate toxicity. Patients should be closely monitored. Leucovorin dosages may need to be increased and administered for longer periods of time. -Probenecid: Decreased renal

fatigue/malais herbal medicines, e and before you start headache treatment with Essentiale. 5. Tell the physician before taking any new medication while taking this one, to ensure that the combination is safe. 6. Do not use the medicine for other health conditions.

tubular secretion of ampicillin and sulbactam when used concurrently; this effect results in increased and prolonged serum concentrations, prolonged elimination halflife and increased risk of toxicity.

Generic Name: Lactulose Brand Name: Contulose Classificat ions Laxative Suggested Mode of Dose Actions 30ml OD Produces HS osmotic effect in colon. Resulting distention promotes peristalsis. Decrease blood ammonia build- up the causes hepatic encephalopa thy, Contraindications Contraindicated in patients on low- galactose diet Drug Interactions Drug-drug. - Should not be used with other laxatives in the treatment of hepatic encephalopathy - Anti- infectives may diminish effectiveness in treatment of hepatic encephalopathy Side Effects/ Adverse Nursing Reactions Responsibilities GI: belching, 1. Asses patient for cramps, abdominal distention, flatulence, diarrhea ENDO: Hyperglycemi a distention, presence of bowel sounds and normal pattern of bowel function. 2. Dissolve single dose packets in 4 oz. of water. Solution should be colorless to slightly pale yellow. 3. Encourage patient to use other forms of bowel regulation, such as increasing mobility.

Indications constipation - To prevent and treat hepatic encephalopa thy, including hepatic precoma and coma I patients with severe hepatic disease.

probably ass - to induce bowel result of

bacterial degradation which lowers pH of colon contents. Relieves constipation , decreases ammonia concentratio n.

evacuation in geriatric patients with colonic retention of barium and severe constipation after a barium meal examination - to restore bowel movements after hemorrhoid ectomy.

Normal bowel habits are individualized and may vary from 3 times/day to 3 times/wk. 4. Caution patient that this medication may cause belching, flatulence, or abdominal cramping. Health care professional should be notified if this becomes botherspme or if diarrhea occurs.

Generic Name: Piracetam Brand Name: Contulose Classificat Suggested Mode of ions Dose Actions Nootropic 1.2 g., Piracetam 1tab improves the TID function of the ContraIndications indications Stroke, Piracetam is ischemia contraand indicated in symptoms patients with severe renal neurotransmitter impairment acetylcholine (renal creatinine via muscarinic clearance of cholinergic less than 20 ml per minute), (ACh) receptors hepatic (liver) which are impairment and to those under implicated in 16 years of age. memory It is also contraindicated processes. in patients with Furthermore, cerebral haemorrhage Piracetam may and in those have an effect with hypersensitivity on NMDA to piracetam, glutamate other pyrrolidone receptors which derivatives or Drug Interactions Drug-drug. A single case has been reported in which the concomitant use of Piracetam and thyroid hormone extracts (T3 + T4) has produced confusion, irritability and sleeping disorders. Its Side Effects/ Adverse Reactions Anxiety, insomnia, irritability, headache, agitation, nervousness, and tremor, are occasionally reported. Nursing Responsibilities 1. Seek the advice of a health care professional before using. 2. Keep Out of Reach of Children. 3. Abrupt suspension of treatment should be avoided, since this can cause a myoclonic or general crisis in certain myoclonic patients. 4. The daily dosage (to be broken down into 2 or 3 doses) and length of treatment are to be established by the doctor, depending on

are involved with learning and memory processes.

any of the excipients.

interaction with other drugs has not been described.

the state and clinical evolution of the patient. 5. Piracetam is nontoxic even in high doses. Massive accidental overdose can be treated either orally or intravenously with forced diuresis or dialysis in the case of renal insufficiency. In the event of overdose or accidental swallowing, consult a doctor.

Generic Name: Atorvastatin calcium Brand Name: Lipitor

Classification Antilipemics

Suggested Mode of Dose Action 80 mg ½ Inhibits tab OD @ HMG-CoA HS – NGT reductase, an early (and ratelimiting) step in cholesterol biosynthesis

Drug Interactions - Adjunct to diet to - Contraindicated - Antacids, reduce LDL, total in patients cholestyramine, cholesterol, hypersensitive to cholestipol: apolipoprotein B, drug and in those May decrease and triglyceride with active liver atorvastatin levels and to disease or level. Monitor increase HDL unexplained patient. levels in patients persistent - Cyclosporine, with primary elevations of diltiazem, fibric hypercholesterolem transaminase acid derivatives, ia levels macrolides - Heterozygous - Contraindicated (azithromycin, familial in pregnant and clarithromycin, hypercholesterolem breastfeeding erythromycin, ia women and in telithromycin), - to reduce the risk women of nefazodone, of MI, stroke, childbearing age niacin, protease angina, or - Use cautiously inhibitors, revacularization in patients with verapamil: may procedures in history of liver decrease patients with disease or heavy metabolism of multiple risk factors alcohol use HMG-CoA for CAD but who - Withhold or reductase don’t yet have the stop drug in inhibitors, disease patients at risk for increasing renal failure toxicity. caused by Monitor patient rhabdomyolysis for adverse resulting from effects and trauma; in report serious, acute unexplained conditions that muscle pain. suggest - Digoxin: May myopathy,; and in increase digoxin major surgery, level. Monitor severe acute digoxin level infection, and patient for hypotension, evidence of uncontrolled toxicity. seizures, or - Fluconazole, severe metabolic, itraconazole, endocrine, or ketoconazole,

Indication

Contraindication

Adverse Effects - CNS: headache, asthenia, insomnia. - CV: peripheral edema - EENT: pharyngitis, rhinitis, sinusitis - GI: abdominal pain, constipation, diarrhea, dyspepsia, flatulence, nausea. - GU: UTI - Musculoskeletal: rhabdomyolysis , arthritis, arthralgia, myalgia - Respiratory: bronchitis - Skin: rash - Other: allergic reactions, flulike syndrome, infection

Nursing Responsibilities - Teach patient about proper dietary management, weight control, and exercise. Explain their importance in controlling high fat levels. - Warn patient to avoid alcohol. - Tell patient to inform prescriber of adverse reactions, such as muscle pain, malaise, and fever. - Advise patient that drug can be taken at any time of day, without regard to meals. - Use only after diet and other nondrug therapies prove ineffective. Patient should follow a standard low-cholesterol diet before and during therapy. - Before treatment, assess patient for underlying causes for hypercholesterolemia and obtain a baseline lipid profile. Obtain periodic liver function test results and lipid levels before starting treatment and at 6 and 12 weeks after initiation, or after an increase in dosage and periodically thereafter. - Drug may be given as a single dose at any time of day, with or without food.

Generic Name: Mupirocin Brand Name: Bactroban

Classification - Local antiinfectives - antibiotic

Suggested Dose Apply ointment TID

Mode of Action Inhibits bacterial protein synthesis by reversibly and specifically binding to bacterial isoleucyl transferRNA synthetase

Indication - Impetigo - Traumatic skin lesions infected with staphylococcus aureus or streptococcus pyogenes - To eradicate nasal colonization by methicillinresistant S. aureus in adult patients and health care workers

Contraindication - Contraindicated in patients hypersensitive to drug. - Use cautiously in patients with burns or large open wounds and in those with impaired renal function because serious renal toxicity may occur

Drug Interactions - Chlorampenicol: May interfere with the antibacterial action of mupirocin on RNA synthesis. Monitor patient for clinical effect.

Adverse Effects - CNS: headache - EENT: pharyngitis, rhinitis, sinusitis, burning or stinging with intranasal use - GI: taste perversion, nausea, abdominal pain, ulcerative stomatitis - Respiratory: upper respiratory tract congestion, cough with intranasal use. - Skin: burning, pruritus, stinging, rash, pain, erythema with topical use.

Nursing Responsibilities - Tell patient to notify prescriber immediately if condition doesn’t improve or gets worse in 3 to 5 days - Tell patient not to use other nasal products with mupirocin - Warn patient about local adverse reactions related to drug use - Caution patient not to use cosmetics or other skin products on treated area - Drug is not for ophthalmic or internal use - Prolonged use may cause overgrowth of nonsusceptible bacteria and fungi - Local reactions appear to be caused by polyethylene glycol vehicle

Generic Name: Mannitol Brand Name: Osmitrol

Classification Osmotic Diuretics

Suggested Dose - 60 cc x 30 mins. q 4 - 20 ml IV for 30 mins. now - 120 cc q 4 to run 30 mins. - 100 cc q 4 x 30 mins.

Mode of Action Increases osmotic pressure of glomerular filtrate, inhibiting tubular reabsorption of water and electrolytes; drug elevates plasma osmolality, increasing water flow into extracellular fluid.

Indication - To prevent Oliguria. - To prevent renal failure - To reduce intraocular or intracranial pressure - Diuresis in drug intoxication - Irrigating solution during transurethral resection of prostate gland

Contraindication - Contraindicated in patients with annuria; frank pulmonary edema; active intracranial bleeding; severe dehydration; metabolic edema; previous progressive renal disease or dysfunction after starting drug, including increasing azotemia and oliguria; or previous progressive heart failure or pulmonary congestion after drug.

Drug Interactions - Lithium: May increase urinary excretion of lithium. Monitor lithium level closely.

Adverse Effects - CNS: seizures, dizziness, headache, fever - CV: edema, thrombophlebitis, Hypotension, hypertension, heart failure, tachycardia, angina-like chest pain, vascular overload - EENT: Blurred vision, rhinitis - GI: thirst, dry mouth, nausea, vomiting, diarrhea - GU: urine retention - Metabolic: dehydration - Skin: local pain,urticaria - Other: chills

Nursing Responsibilities - Tell patient that he may feel thirsty or have a dry mouth, and emphasize importance of drinking only the amount of fluid s ordered - Instruct patient to promptly report adverse reactions and discomfort at I. V. site - Monitor vital signs, including central venous pressure and fluid intake and output hourly. Report increasing oliguria. Check weight, renal function, fluid balance, serum and urine and potassium levels daily. -To relieve thirst, give frequent mouth care or fluids - Drug can be used to measure GFR

Generic Name: Salbutamol sulfate Brand Name: Provexel

Classification - Antiasthmatic - Broncho dilator

Suggested Dose I neb with ambroxol for inhalation 10 gtts + PNSS TID

Mode of Action Increasing the levels of the energy producing substance called cAMP. Inhibiting PDE the enzyme that breaks down cAMP. Subsequently, this causes smooth muscle relaxation and broncchodilati on; also inhibits release of chemical mediators such as histamine

Indication - Symptomatic relief of bronchospasm in obstructive airway diseases - Bronchial asthma, -emphysema -chronic bronchitis.

Contraindication - Contraindicated in patients with hypersensitivity to the drug

Drug Interactions -Allopurinol -Cimetidine -Erythromycin -Flu Vaccine -Oral Contraceptives

Adverse Effects Tachycardia, palpitations, flushing, fine tremor of skeletal muscles, nervousness, tension, headaches, muscle cramps.

Nursing Responsibilities - Tell patient to inhale the smoke release by the nebulization - Advise patient to inform the medical team if any adverse reactions occur - Perform back tapping after nebulization to help expectorate phlegm - Watch out for any secretions and notify the physician.

Generic Name: Hexetidine Brand Name: Bactidol

Classification

Suggested Dose - Antiseptic Hold 15mouthwash 20 mL in - Antithe mouth. bacterial Swish & - Anti- fungal gargle for 30 sec in the morning & evening. Use full strength.

Mode of Action Inhibit protein synthesis by binding to a portion of the bacterial ribosome

Indication - Minor sore throat - Halitosis - General oral hygiene - Improves appearance of mouth tissues - Protects tooth surfaces against formation of decay acids.

Contraindication - Contraindicated in patients hypersensitive to drug. - Use cautiously in children ages 6 and below

Drug Interactions No known drug interaction

Adverse Effects - Transient numbness & alteration in taste may occur.

Nursing Responsibilities - Tell patient to carefully gargle bactidol and avoid swallowing it. - Inform patient that he can mix bactidol with minimal amount of water to reduce its strong taste

NURSING THEORIES
Nursing Theory Imogene King (Goal attainment theory) Description Imogene King's model is a model of three interacting systems: personal, interpersonal, and social. In her theory of goal attainment, she states that client goals are met through the transaction between nurse and client. The model can be applied to all settings. Her model is based on systems theory but has also been classified as an interaction model. Application to the patient As health provider we need to learn how to interact with our patient. We must encourage them to verbalize feelings in order for us to provide interventions necessary to the patient’s condition. Through a good therapeutic communication it will give us complete verification in which it will lead us to a good attainment. As a student nurse our goal is to help persons gain a higher degree of harmony within the mind, body, and soul which generates self-knowledge, self-reverence, self-healing, and self-care. We need to alleviate that certain kind of illness; thus, it will lead to the promotion of a good health. We must also focus on how to care patient’s who really needs special attention. And to effectively accomplish patient’s cooperation we must learn how to gain trust to them, in the end we can easily instill hope and cooperation for fast recovery.

Jean Watson (human caring relationship theory The main concept of the theory is transpersonal human caring, which is best understood within the concepts of three ancillary concepts: LIFE, ILLNESS, and HEALTH. HUMAN LIFE is defined as spiritualmental-physical being-in-the-world, which is continuous in time and space. ILLNESS is not necessarily disease. Illness is subjective turmoil or disharmony with a person's inner self or soul at some level or

disharmony within the spheres of the person, either consciously or unconsciously. HEALTH refers to unity and harmony within the mind, body, and soul. Dorothy Johnson (behavioral system model)

Johnson states that a nurse should use the behavioral system as their knowledge base; comparable to the biological system that physicians use as their base of knowledge. The reason Johnson chose the behavioral system model is the idea that "all the patterned, repetitive, purposeful ways of behaving that characterize each person's life make up an organized and integrated whole, or a system".

As a nurse, we need to identify our patient’s coping abilities regarding to stress. We must also identify such contributing factors to enable us to provide nursing care to prevent the occurrence of such problem and for the patient to meet his needs,

Date A P R I L 3 0, 2 0 0 9 @ 2 P

Cues S/OBJECTIVE: - Hemiparesis noted at the right side - absence of voluntary movements of the extremities, muscle tone, body posture, and head position - difficulty ambulating -needs assistance when moving

Need A C T I V I T Y E X E R C I S E

Nursing Dx Impaired physical mobility related to hemiparesis, loss of balance and coordination and brain injury secondary to CVA RATIONALE Due to brain damage caused by stroke its resulting

Objective of Care At the end of our shift, the patient will be able to improved mobility as evidenced by: a.) independent slow movement of the extremities from one side to another

Nursing Interventions 1.) Determine existing condition affecting level of own ability of individual to move ® To identify causative/ contributing factors 2.) Determine degree of

Evaluation GOAL MET April 30, 2009 After 8 hours of span of care, the patient was able to improve evidenced by: a) trying to flex extremities b) slow movement of the body from one side to another

perceptual/ cognitive impairment mobility as ® to identify the necessary interventions to be done 3.) Observe movement when client is unaware of observation ® to note any incongruencies with reports of abilities 4.) Assist client reposition himself frequently on a regular basis ® to promote ability to move independently

b.) slow movement of body and ability to follow directions

M P A T T E R N

effect is the limitation in independent, purposeful physical movement of the body or of one or more extremities

5.) Instruct client to move from side to side frequently ® to promote ability to move independently and to avoid bed sores 6.) Consult with physical/ occupational therapists as indicated ® to develop individual exercise/ mobility program and identify appropriate adjunctive devices 7.) Identify energy-conserving techniques for ADL’s. ® limits fatigue, maximizing participation

Date/time April 30, 2009 @ 3:00 pm S/O:
-

Cues

Needs R O L E R E L A T I O N S H I P P A T T E R N

right sided weakness Aphasia with NGT Vital signs

BP- 130/ 90 mmHg RR- 25 bpm PR- 68 bpm

TEMP38.1 °C

Nursing diagnosis Impaired verbal communication r/t alteration in central nervous system 2° CVA ® Decreased, delayed, or absent ability to receive, transmit, process, and use a system of symbols. Reference: Nurse’s Pocket Guide 10th edition p. 65 By: Doenges, Moorehouse and Murr

Objectives/goals Within our 6 hour span of care, our patient will be able to establish method of communication in which needs can be expressed.

Intervention 1.Monitor patient’s vital signs ® serves as baseline data. 2.Determine ability to write. Evaluate musculoskeletal states, including manual dexterity (e.g. ability to hold a pen and write). ® to assist client to establish a means of communication 3. Obtain a translator/written translation or picture chart ® to assist client to establish a means of communication when writing is not possible. 4. Facilitate hearing and vision examinations/obtaining necessary aids. Assist client to learn and adjust to aids. ® for improving the patient’s communication skills 5.Establish relationship with the client, listening carefully and attending to client’s nonverbal expressions. ® to assist client to establish a means of communication 6.Keep communication simple, using all modes for accessing information: visual, auditory, and kinesthetic. ® for the patient to easily understand messages and relay nonverbal communication skills 7.Maintain a calm, unhurried manner. Provide sufficient time for the client to respond. ® individuals with expressive aphasia may talk more easily when they are rested and relaxed. 8.Validate meaning of nonverbal communication; do not make assumptions. ® there is a tendency that

Evaluation April 30, 2009 @ 9:00 pm GOAL MET! Patient was able to establish method of communication in which needs can be expressed.

Date A P R I L 3 0, 2 0 0 9 @

Cues S/OBJECTIVE: - unkempt hair noted -halitosis noted - several days without bathing hygiene as verbalized by the watcher

Need S E L F P E R C E P T I O N S E

Nursing Dx Self- care deficit r/t pain and discomfort RATIONALE Pain is a typical sensory experience that may be described as the unpleasant awareness of a noxious stimulus or bodily harm. Individuals experience pain by

Objective of Care At the end of our shift, the patient will be able to demonstrate techniques to meet self- care needs as evidenced by: a.) verbalization of the client’s watcher the importance of maintaining a good personal hygiene b.) watcher will be able to demonstrate ways in maintaining the client’s personal hygiene.

Nursing Interventions 1.) Determine existing condition affecting level of own ability of individual to care for own needs ® To identify causative/ contributing factors 2.) Determine individual strengths and skills of the client and note whether the deficit is permanent or temporary ® To assess degree of disability 3.) Promote client’s watchers participation in problem identification ® To enhance commitment to plan optimizing outcomes 4.) Allow sufficient time for the client’s watcher to accomplish task ® To assist in dealing with the situation

Evaluation GOAL MET April 30, 2009 After 5 hours of span of care, the patient’s watcher was able to demonstrate techniques to meet self- care needs as evidenced by: a) fingernails well- trimmed b) able to fix hair with assistance

P M

L F

C O N C E P T P A T T E R N

various daily hurts and aches, and occasionally through more serious injuries or illnesses, thus, the practice of self- care activities that an individual initiates and perform on their own behalf in maintaining life, health and well being is affected.

5.) Assist with necessary adaptations to accomplish ADL’s ® To aid the client in achieving task 6.) Provide privacy during personal care activities ® To provide privacy to the client 7.) Provide for communication among those who are involved in caring/ assisting the client ® To enhance coordination and continuity of care 8.) Encourage the family to assist the client in performing self- care activities ® To promote wellness

c.) able to gargle with bactidol with assistance d.) able to change clothes with assistance

(http://current nursing.com/n ursing_theory/ self_care_defi cit_theory.ht m)

Date/ Time

Cues

Need

Nursing Diagnosis

Objective of Care

Nursing Intervention with Rationale

Evaluation

A P R I L 30 , 2009 @ 5pm

S/O:
-

-

Right- sided hemiparesis noted With NGT noted Vital signs: BP- 130/ 90 mmHg RR- 25 bpm PR- 68 bpm TEMP- 38.1 °C

A C T I V I T Y E X E R C I S E P A T T E R N

Activity Intolerance related to rightsided weakness of the body secondary to Cerebrovascular Accident, infarct, left middle cerebral artery ® Insufficient physiological or psychological energy to endure or complete required or desired daily activities Reference: Nurse’s Pocket Guide 10th edition p. 65 By: Doenges, Moorehouse and Murr

Within our 3 hours span of care, the patient will be able to demonstrate a decrease in physiological signs of intolerance as evidenced by stable vital signs.

1. Monitor Vital Signs ® VS serves as the baseline date 2. Note presence of factors contributing to weakness. ® to identify causative/ precipitating factors 3. Evaluate current limitations/ degree of deficit in light of usual status. ® provides comparative baseline 4. Assist with activities and provide/ monitor client’s use f assistive devices ® to protect from injury 5. Provide referral to other discipline as indicated ® To develop individually appropriate therapeutic regimens.

Goal MET! April 30, 2009 @ 8 pm Within our 3 hours span of care the patient was able to demonstrate decrease in physiological signs of intolerance as evidenced by stable Vital Signs. BP- 120/90 mmHg RR-20 bpm PR- 68 bpm Temp- 37 °C

6. Encourage to perform range of motion exercises. ® to promote circulation 7. Review expectations of client/ Significant others ® to establish individual goals 8. Assist client in learning and demonstrating appropriate safety measures ® to prevent injuries

Date/Time April 30, 2009

Cues S/O: - Flushed N U

Needs

Nursing Diagnosis Hyperthermia r/t release of endogenous pyrogens as

Objective/Goal Within my 1-3 hour span of care, my

Intervention 1. Monitor patient’s vital signs.

Evaluation April 30, 2009 @

@ 5:00pm

-

skin Warm to touch Irritability noted Restlessne ss noted VITAL SIGNS:

T R I T I O N A L -

evidenced by increase in temperature above normal range R: Hyperthermia is the elevation of body temperature above normal range. Most often, it results from infection somewhere in the body, but it may be caused by other conditions (cancer, allergic reactions, and CNS injuries). Macrophages, white blood cells, and injured cells release chemical substances called pyrogens that act directly on the hypothalamus, causing its thermostat to be set to a higher temperature. SOURCE: Nursing Diagnosis Manual by Doenges, Moorhouse, Murr. Essentials of Human Anatomy and Physiology (page 490) by Elaine Marieb

patient’s body temperature will decrease from 38.1 °C to 36.5-37.5°C.

BP130/ 90 mmHg RR- 25 bpm PR- 68 bpm TEMP- 38.1 °C

M E T A B O L I C P A T T E R N

® serves as baseline data 2. Note chronological and developmental age of client. ® infants, young children, and elderly persons are most susceptible to damaging hyperthermia. Environmental factors and relatively minor infections can cause a much higher temperature in them. They are also not able to protect themselves, and cannot recognize and/or act on symptoms of hyperthermia. 3. Provide cool/tepid sponge bath ® promotes heat loss by evaporation and conduction 4. Limit clothing/dressing in lightweight, loosefitting clothes. ® encourages heat loss by radiation and conduction.

8:00 pm GOAL MET Patient’s body temperature decreased from 38.1 °C to 36.8 °C

5. Cool the environment with air-conditioning or fans. ® promotes heat loss by convection 6. Lavage body cavities with cold water in presence of malignant hyperthermia ® to promote core cooling 7. Keep clothing and linens dry. ® to reduce shivering 8. Offer/force plenty of fluids, even if client is not thirsty ® to replace fluids lost through perspiration and respiration. 9. Maintain bedrest ® to reduce metabolic demands/oxygen consumption. 10. Collaborate with dietician in providing patient with high-calorie diet, or parenteral nutrition ® to meet increased

metabolic demands 11. Notify physician if pharmacologic regimen is inadequate to meet hyperthermia control goal. ® to determine if there is a need to increase dosage, change medication or use a stepped program (e.g., switching from injection to oral route, or lengthening time interval between doses). 12. Administer antipyretics, orally or rectally, as ordered. ® to aid in reducing fever 13. Provide supplemental oxygen as ordered. ® to offset increased oxygen demands and consumption. 14. Administer replacement IV fluids and electrolytes as ordered. ® to support circulating

volume and tissue perfusion and to aid in hydration

DISCHARGE PLAN

Medicines

Discuss with the patient and watcher the need to comply with home medications.

® 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 watcher the right time, right medications, right dosage, and right route 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 and watcher the importance of taking consideration of the foods or 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 others about the possible effects and adverse reactions that may occur brought about by taking the medications.

® Side effects and adverse reactions from the medications will sometimes lead into another occurrence of complication or disease. This will also facilitate proper medical assistance.

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.

Encourage the patient not to take medications not prescribed by the physician.

® Non-prescribed drug may contain antagonistic or synergistic effect.

Instruct the patient not to stop the medication abruptly or adjust the dosage without prescription of the physician.

® Stopping the medication abruptly or adjusting the dosage would not take the effect or action of the medication.

Instruct the family to properly store and handle the medications so as not to let children accidentally get hold of it.

® This will prevent accident of drug poisoning.

Exercise/Environment

Encourage the patient to perform light exercises such as walking and jogging.

® Exercise helps reduce cholesterol levels in the biliary tract, which could help prevent gallstones.

Avoid heavy exercises.

® To prevent the risk of tearing the incision site and also to prevent body fatigue.

Treatment

Explain the purpose of the 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 her understand about the importance of taking the prescribed drugs for faster recovery in the disease process. To also make them aware that the treatment is not only done in the hospital but it should be continued at home.

Explain to the family the condition of the patient and give them factual information.

® To have better understanding of the condition of the patient and to make appropriate action of the disease.

Direct and instruct the watcher to give the 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 patient’s 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 to practice proper hand washing before and after eating.

® Proper hand washing will prevent the spread of microorganisms.

Instruct patient to do activities of daily living.

® 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 patient and family to have a 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 doctor’s order comply with the doctor’s advice and follow what is stated in the written discharge instruction.

® Following the doctor’s advice 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 patient’s condition.

® Signs of unusualities will indicate the occurrence of the disease and reporting it immediately to the health care providers will immediately give enough attention to treat the said complaint.

Diet

Avoid crash diets or a very low intake of calories — less than 800 calories a day.

® Losing weight too quickly is associated with an increased risk of gallstones.

Choose a low-fat, high-fiber diet that emphasizes fresh fruits, vegetables and whole grains. Reduce the amount of animal fat, butter, margarine, mayonnaise and fried foods in daily meal.

® A high-fiber, low-fat diet helps keep bile cholesterol in liquid form. Do not cut out fats abruptly or eliminate them altogether, as too little fat can also result in gallstone formation.

Eat regular meals, 5 or 6 small meals per day.

® This helps to avoid overloading the digestive system and allows the body more time to digest any fats.

PROGNOSIS

Onset of illness

Poor(1) /

Fair(2)

Good(3)

Duration of illness

/

Precipitating factor

/

Justification Mr. Eks’ onset of illness is poor because his illness was sudden. Prior to Mr. Eks’ admission at Limso Hospital, he stayed 4 days at Cateel Hospital and during our last day of duty at Limso it was his 10th day at the hospital. He has been hospitalized for about two weeks already. Most of the precipitating factors are present in Mr. Eks.

Predisposing factor Willingness to follow treatment regimen Family support

/

/

/

Almost half of the Predisposing factors are present in the patient. The patient is willing to take and comply with his treatment regimen because he knows it is for her own benefit. During our duty in the hospital, his family was always there and did not leave him alone.

TALLY Poor: (1 x 4) = 4 Fair: (2 x 0) = 0 Good: (3 x 2) = 6 Total: 10/6 = 1.7 Ranges: 1.0 – 1.5 = POOR 1.5 – 2.5 = FAIR 2.5 – 3.0 = GOOD Impression:

After evaluating our client, we have rated the client’s prognosis as FAIR. Even though half of his body can no longer regain its previous functions Mr. Eks still can have a normal life after seeking for medical assistance. Also the willingness of the client in taking his medications and supportive family will help her cope with the situation productively.

Recommendation
For the family:

We recommend that the family will still continue to give the patient love and support. It could still help the patient survive when there is a strong bond of relationship within the family. The family must learn to understand the patient’s situation. They must also be aware of some medications that are really needed for the patient. They must find ways and means to comply with such certain meds, because if patient is left untreated then it will lead to certain complications that will even more add up to the expected amount.

For the patient: The patient should be aware with his condition. He must be well oriented of the facts about the things that she should be alarmed of. We recommend that the patient will be complying all the medications given to him by the physician. And as a patient he must follow all the doctor’s guidelines to him. He must discipline himself to all the things that must be avoided. Also, patient must learn the importance of proper hygiene in order to lessen other possible infections.

For the community: CVA or stroke is not always preventable for those at risk, however, steps can be taken to lower the chance to develop and to delay the possible outcome. That’s why we want to recommend that we must stay healthy as much as possible.

BIBLIOGRAPHY
• •

Blackwell’s Dictionary of Nursing Contemporary Medical Surgical Nursing

Smeltzer, S. & Bare, B. (2004). Bruner & Suddarth’s Textbook of Medical Surgical Nursing. (10th Ed.) Philadelphia: Lippincott Williams Wilkins. Cotran, R., Kumar, V., & Robbins, S. (1994). Robbins Pathologic Basis of Disease. (5th Ed.) Philadelphia:W.B. Saunders Company. Gould, B.E. (2006). Pathophysiology for the Health Professions. (3rd ed). Philadelphia: Saunders Elsevier Monahan, F.D et al. (2007). Phipps’ Medical-Surgical Nursing. Health and Illness Perspectives. Canada: Mosby Elsevier Nelms, M., Sucher, K., Long, S. (2007). Nutrition, Therapy & Pathophysiology. Australia: Thomson Wadsworth. Porth, C.M. (2002). Pathophysiology. Concepts of Althered Health States. (6th ed). Lippincott Williams and Wilkins Spratto, G., Woods, L. (2007). 2007 edition PDR Nurse’s Drug handbook. Thomson Corporation. Sparks, S., Taylor, C. (1995). Nursing Diagnosis Reference Manual. (3rd Ed.). Springhouse Corporation. Deglin, S., Vallerand, B., (1994). Davis’s Drug Guide for Nurses (5th Ed.). Thomson Corporation. Nursing 2008 Drug Handbook 28th Edition by Lippincott Williams and Wilkins http://www.medicinenet.com/gallstones/page3.htm www.nursingcrib.com www.wikipedia.com www.mims.com Davis’ Drug Guide 9th edition Medical- Surgical Handbook by Springhouse

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