Pamantasan ng Lungsod ng Pasig Alcalde Jose St.

, Kapasigan, Pasig City COLLEGE OF NURSING

CASE STUDY:

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

Submitted by: Professor Allan David Alcantara

November 2012

INTRODUCTION

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

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

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Diagnosis is usually based on symptoms and results of a physical examination, imaging tests, and blood tests.

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

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

ANATOMY AND PHYSIOLOGY
The Central Nervous System is made up of the brain and spinal cord. The spinal cord transports sensory and motor information from other parts of the body to the brain. With the spinal cord, the brain monitors and regulates many unconscious bodily processes such as heart rate and breathing, and coordinates most voluntary movements. Most important, it is the site of consciousness and of all the intellectual functions that allow humans to think and create. This information is carried through impulses from a neuron. Neuron is consists of a nucleus situated in the cell body, where outgrowths called processes originate from. The main one of these processes is the axon, which is responsible for carrying outgoing messages from the cell. This axon can originate from the central nervous system (CNS) and extend all the way to the body's extremities, providing an efficient highway for messages. Dendrites are smaller secondary processes that grow from the cell body and axon. On the end of these dendrites lie the axon terminals, which plug into a cell where the electrical signal from a nerve cell to the target cell can be made. This 'plug' (the axon terminal) connects into a receptor on the target cell and can transmit information between cells. The brain can be subdivided into several distinct regions: The cerebral hemispheres form the largest part of the brain, occupying the anterior and middle cranial fossae in the skull and extending backwards over the tentorium cerebelli. They are made up of the cerebral cortex, the basal ganglia, tracts of synaptic connections, and the ventricles containing CSF. The Diencephalon includes the thalamus, hyopthalamus, epithalamus and subthalamus, and forms the central core of the brain. It is surrounded by the cerebral hemispheres. The Midbrain is located at the junction of the middle and posterior cranial fossae. The Pons sits in the anterior part of the posterior cranial fossa- the fibres within the structure connect one cerebral hemisphere with its opposite cerebellar hemisphere.

The impulses generated and carried by it is an example of the chemical level of organization of the body. . The Cerebellum overlies the pons and medulla. and is responsible for automatic control of the respiratory and cardiovascular systems. and posture. It is mainly concerned with motor functions that regulate muscle tone. This nerve impulses then regulate the functioning of tissues. coordination. which permits us to perceive and respond to the world around us and the changes within us.The Medulla Oblongata is continuous with the spinal cord. extending beneath the tentorium cerebelli and occupying most of the posterior cranial fossa. Brain regulates many of our activities. organ and organ system.

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

the client was using a walker. he doesn·t want to exercise much because he was afraid of getting fatigued. Feeding . Now.3 General mobility . he was in a general liquid diet. He also used to watch television and read a dictionary. Nutrition/Metabolic Pattern According to the client·s daughter and wife. Now. the client used to consult a doctor every time he was having problems with his health. it was said that he was smoking and drinking alcohol during his teenage life.3 Note: Level 0: Full Self-Care Level 1: Requires use of equipment or device Level 2: Requires assistance/supervision from another person Level 3: Require assistance/supervision from another person/device Level 4: Is dependent and does not participate Bathing . and used to exercise with it for some time. including jelly ace. Also. and then become hypertensive. but was able to get out of it when he was married with his wife. soup and etc. Activity-Exercise Pattern Before. the client voids less frequently and defecates about three times a day. According to them.3 Toileting . the client urinates frequently and defecates usually twice a day before he was hospitalized. Now.3 . He also eats pork and vegetables sometimes. According to his daughter.3 Bed mobility .FUNCTIONAL HEALTH PATTERN Health Perception/Health Management Pattern The client wasn·t able to state anything about his perception of his general health. They also mentioned that his favorite drink was Sprite. but he was crying every time his daughter was being asked about something that he can do before but cannot do now. the client was fond of eating about 3 cups of rice each meal and drinking more than 1500 ml of water a day before he was hospitalized.3 Dressing . Elimination Pattern According to the client·s daughter. he just used to listen to a music and sleep.2 Grooming .

but it was obvious to the client that he was not feeling good about himself because he cries whenever some changes about his abilities are being mentioned. he had direct sexual feelings towards other that lead to sexual gratification. Also. verbal response was 3. Now. Coping-Stress Tolerance Pattern According to his daughter. . The client was in Genital Stage according to Sigmund Freud Psychosexual Theory. and his motor response was 2. her parents are of a long distance relationship before. He was an active Born Again Christian before he was hospitalized. They had a good relationship since then. but was being interrupted from time to time. his wife runs a small business and takes care of him. Sexuality/Reproductive Pattern According to the client·s daughter. The client looks uncomfortable when strangers talk to him. because he had physical sexual changes that reawaken his repressed needs. the client values his family and religion. with his job as a policeman. he had longer time for sleep since he lies on bed almost all the time. Role/Relationship Pattern The client was the breadwinner of his family before. Therefore. Cognitive Pattern The client easily responds to people he knows but does not respond to strangers. Thus. his eye response was scored as 4. he was in GCS-9. In Glascow-Coma Scale. he was not sexually active before and until now. Now. Value-Belief Pattern According to his daughter. He also has no problems sleeping then. he used to pray every time he encounters a problem. and so she was the only daughter of the couple. his sleeps about eight hours every night and takes short naps before he was hospitalized. Self-Perception/Self-Concept Pattern The client wasn·t able to express much of his own perception subjectively.Sleep-Rest Pattern According to his daughter.

Ears y Pinnae symmetrical y (+) hearing on both sides 6. nipple masses y (-) edema. Neck y Trachea in midline y Non-palpable thyroids y Non-palpable cervical lymphnodes y (-) neck enlargement y Normal ROM 9.. Pasig City Vital Signs: T ² 36. Nagpayong 2. 2010) Name: Mr. Eyes y anicteric sclera y lids symmetrical y pink palpebral conjunctiva 5. and fine distribution y (-)alopecia 4. Head y Symmetric face y Normal hair. Nose y Symmetrical y Septum in midline (-) perforation y Both nares patent y Pinkish mucosa Status: Married 7. General Survey y weak looking y conscious and coherent y GCS=15 2. Mouth y (-)dentures y Slurring of speech y (-) lesions y Tongue in midline y (+) caries y Gums pinkish y Uvula in midline y Tonsils not inflamed y dry buccal mucosa 8. Breast and Axillae y Equal size.PRE PHYSICAL EXAMINATION (November 07. Chest and Lungs y Symmetrical chest expansion y (-) wheezes y (-) dullness y (-) retraction y Clear breath sounds . Skin y (+) pallor y (+) dryness 3. symmetrical y (-) discharge. tenderness 10.5°C P ²87 R ² 26 BP ² 180/100 1. Felix Agoncillo. Jr Age: 46 y/o Gender: Male Address: #9913 Aguinaldo St.

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

Neck y Trachea in midline y Non-palpable thyroids y Non-palpable cervical lymphnodes y (-) neck enlargement y Normal ROM 9.. Felix Agoncillo.POST PHYSICAL EXAMINATION (November 29. Head y Symmetric face y Normal hair. Mouth y (-)dentures y (-) lesions y Tongue in midline y (+) caries y Gums pinkish y Uvula in midline y Tonsils not inflamed y dry buccal mucosa 8. symmetrical y (-) discharge. Skin y Poor skin turgor y Hooked IVF: PNSS 1L x 16° y (-) dryness 3. General Survey y Awake y conscious and coherent y On supine position y GCS=8 2. Eyes y anicteric sclera y Lids symmetrical y Eyes symmetrical y pink palpebral conjunctiva 5. Jr Age: 46 y/o Gender: Male Address: #9913 Aguinaldo St. Chest and Lungs y Symmetrical chest expansion y (+) wheezes y (-) dullness y (-) retraction y (-) murmur . nipple masses y (-) edema. Ears y Pinnae symmetrical y (+) hearing on both sides 6. Breast and Axillae y Equal size.6°C P ²84 R ² 26 BP ² 130/90 1. tenderness 10. Pasig City Vital Signs: T ² 36. 2010) Name: Mr. and fine distribution y (-)alopecia 4. Nagpayong 2. Nose y Symmetrical y Septum in midline (-) perforation y Both nares patent y Pinkish mucosa Status: Married 7.

Abdomen y (-) lesions y (-) rashes y (-) striae y Umbilicus is not bulging y Flat abdomen y No tenderness 12.11. Back and Extremities y Pale nail beds y Peripheral pulses is symmetrical y (-) clubbing y Tone normal y Spine is in the midline y (-) edema y Swelling of both lower extremities y With wound at left foot y Right sided paralysis y Dry toe y With metal inside the thigh and legs .

04 normal .0 mmol/L 10-14 sec.2-7.17 decreased Monocyte 0.40 0.3 mmol/L 3.LABORATORY FINDINGS Date Laboratory Tests BUN Normal Values 3.10 sec.35-0.6-5.1 mmol/L 3.4 sec. Malnutrition NA 2.8x109/L normal NA Infection.5011.08 0.45 g/L normal NA Platelet Count ADEQUAT E normal NA WBC count 6.20-0.6 mmol/L 11.79 increased Lymphocyte 0.9 sec.54 g/L 150400x109/ L 4. 27. decreased Serum potassium Prothrombin Time Activated partial Thromboplas tin time Hemoglobin normal normal NA 28.02-0. 135-160 g/L 0. ischemic neurosis Affection of immune system NA Neutrophil 0.40-0. normal NA 145 g/L normal NA 11-07-10 Hematocrit 0.7034.65 Results Interpretation Indications Severe Hepatic Damage.00x109 /L 0.

89 increased Lymphocyte 0.11 decreased Hemoglobin 146.00x109 /L 0.0 normal 11-22-10 Hematocrit 0.00-3.10sec 28.9sec normal NA 0.44 ADEQUAT E normal NA normal NA 15.8 mmol/L 4.2 mmol/L 1.54 g/L 150400x109/ L 0.35-0.65 135-160 g/L 0.0014.54 g/L 150400x109/ L 4.00sec 11.4sec normal NA 27.5 increased Infection Infection.36 mmol/L 135-160 g/L 0.Prothrombin Time Activated Partial Thromboplas tin Time Serum Total Cholesterol 11-10-10 Serum HDL Cholesterol Serum LDL Cholesterol Hemoglobin 10.0-5.0-1.3 mmol/L 0.40-0.7034.44 normal NA Platelet Count Adequat e normal NA .35-0.65 6.6 mmol/L 0.5011. ischemic neurosis Affection of immune system NA Neutrophil 0.97 mmol/L 149 increased Coronary Artery Disease hypertriglyceri demia Coronary Artery Disease NA decreased increased normal Hematocrit Platelet Count 11-17-10 WBC Count 0.40-0.

ischemic neurosis Affection of immune system NA Neutrophil 0.54 g/L 150400x109/ L 4.89 increased Lymphocyte 0.0 normal NA Hematocrit 0.65 0.02 normal URINE SPECIMEN: 11-10-10 PHYSICAL Color ² yellow Transparency ² slightly turbid pH ² 6.08 0.45 normal NA Platelet Count Adequat e normal NA WBC Count 13.10 decreased Monocyte 11-27-10 0.10 decreased Monocyte 0.65 0.WBC Count 4.40-0.87 increased Lymphocyte 0.negative .5011.030 CHEMICAL TEST Albumin ² negative Sugar .08 135-160 g/L 0.35-0.02-0.5011.02-0.5 Specific Gravity ² 1.35-0.65 13.00x109 /L 0.8 increased Infection Infection.03 normal Hemoglobin 149.35-0.35-0.00x109 /L 0.65 0. ischemic neurosis Affection of immune system NA Neutrophil 0.0 increased Infection Infection.

 The heart is not enlarged.NORMAL CHEST 11-19-10 X-RAY RESULTS CHEST PAIAP (ADULT) Supine:  There are suspicious infiltrates in the left apex. 11-07-10 X-RAY RESULTS CHEST PAIAP (ADULT)  The lungs are clear.  Chronic infarct.  Mild atherosclerotic vessel disease. both fronto-parietal lobes.  Heart & great vessels are within normal size & configuration.  Periventricular ischemic white matter changes. Suggest Apicolordotic view. .  Age-related cerebral volume loss.  Congested left nasal turbinate. right cerebellar hemisphere.  Hemidiaphragms.DIAGNOSTIC PROCEDURE 11-07-10 CT scan: (IMPRESSION)  Acute to subacute non-hemorrhagic infarct. right subinsular cortex & lentiform nucleus. sinuses and visualized osseous structures are intact.  Small right sphenoid sinus mucous retention cyst.  Other chest structures are unremarkable. IMPRESSION: .

Family History of CVA. Age.0. Hypertension.PATHOPHYSIOLOGY OF CVA (STROKE) Predisposing Factors Precipitating Factors Smoking.79 Irbesartan Increase LDL levels - 4. Overweight.Sedentary Life Style. from 80kg to 60kg Average BP: 160/110 Furosemide Hypertension Neutrophil . Race Destruction of alpha and beta cells of the pancreas Failure to produce insulin Production of excess glucagon Inc. Sex (Men). High Cholesterol Level. serum glucose level Production of glucose from protein and fat stores Glycoprotein cell wall deposits Impaired immune function (decrease level of morphonuclear leukocytes) Small vessel disease Wasting of lean body mass Fatigue Weight loss Accelerated atherosclerosis Neuropathy Infection Delayed wound healing Symmetri cal loss of protective sensation Numbness and tingling in the extremities Autonomic neuropathy Wt.97 mmol/L Levofloxacin Dry cracked skin . Excessive Alcohol Consumption.

Thrombus CEREBROVASCULAR ACCIDENT Occludes a blood vessel in the brain Hemiparesis (right side) Results to blockage of blood vessel impeding blood flow Emboli Decreased Tissue perfusion (brain) Continuous build p of pressure Loss of speech Hemisensory loss Impaired tissue perfusion Cerebral Hypoxia Results to increased intracranial pressure Cerebral ischemia Confusionn Altered LOC Short term Ischemia (<1015mins) Citicoline Mannitol Temporary Deficit No permanent damage MID CEREBRAL ARTERY ANTERIOR CEREBRAL A. VERTEBROBASILAR ARTERY Hemiparesis (right side) Aphasia Hemiplegia (left side) Ataxia Hemisensory loss Incontinence Dysphagia Dysarthia . POSTERIOR CEREBRAL A.

symptoms & signs of cerebral insufficiency (dizziness. 7-20 Shifted to tablet by Dec. 20-27 Discontinued by: Dec. and maxillary infection. 60 mg TIV every 8 hours Should not be used against:   Allergy Diarrhea This medication may cause:       Abdominal Cramping Anorexia Diarrhea Vomiting Confusions Uncontrollable Emotions   Date started: Dec. 28  Check culture and sensitivity test to see if this the drug of choice Ensure that full course is given to help prevent emergence of strain. disorientation. lincosamines Indication / Action Dosage & frequency rate Contraindication Adverse Reaction Nursing Consideration Treatment of various respiratory. . recent cranial trauma) Dosage & frequency rate Contraindication Adverse Reaction Nursing Consideration 1gm IV q 12 Date started: Dec. excitement. 20-29 -Parasympathetic -hypertonia This medication may cause: -shocks. Provide small frequent meals to ensure adequate nutrition due to GI upset Generic Name: Citicholine Classification: neurotonics Indication / Action -CVD in acute & recovery phase.DRUG STUDY Generic Name: Clindamycin Classification: Anti-infectives.Somazine must not be administered along with medicaments containing meclophenoxate . sinus. hypotension. poor concentration. memory loss. skin. hypersensitivity. insomnia.

DNA gyrase is an enzyme needed for replication. intraperitoneal. hepatic cirrhosis. his medication may cause:      Headache Dizziness Insomnia Nausea and Vomiting Diarrhea    Obtain baseline assessment Assess patient for previous sensitivity reaction Monitor for possible drug induced adverse reaction Generic Name: Furosemide Classification: Diuretics Indication / Action Dosage & frequency rate Contraindication Adverse Reaction Nursing Consideration Teatment of edema associated with congwstive hearrt failiure (CHF). Monitor Vital signs especially BP Monitor I&O . 40mg tad BID x 3days Should not be used against: Date started: Dec. hypertension. or SC administration. quinolones Indication / Action Dosage & frequency rate Contraindication Adverse Reaction Nursing Consideration Infections caused by susceptible strains of microorganisms in acute maxillary sinusitis.Generic Name: Levofloxacin Classification: Anti-infectives. transcription. and renal disease. acute bacterial exacerbation of chronic bronchitis. intrathecal. 500mg tab OD IM. and repair of bacterial DNA. 17-29   Hypersensitivity to drug Anuria This medication may cause:  Jaundice  Hearing impairement  Tinnitus  Hypotension  Pancreatitis  Abdominal pain    Do not confuse Lasix with Lanoxin (a cardiac glycoside). ACTION: Interferes with DNA gyrase and topoisomerase IV.

30cc OD -Patients who require a low lactose diet. potassium and bicarbonate ions. ACTION: Causes an influx of fluid in the intestinal tract by increasing the osmotic pressure within the intestinal lumen. This medication may cause:  Abdominal discomfort Diarrhea Nausea and vomiting Flatulence   Monitor for possible adverse GI reaction Monitor fluid and electrolyte status Date started: Dec.ACTION: Inhibits the reabsorption of sodium and dichloride in the proximal and distal tuconstibules as well as the ascending loop of Henle. this results in the excretion of sodium. -Galactosaemia or disaccharide deficiency. salmonellosis. to a lesser degree. -Intestinal obstruction.   Dizziness Anemia Generic Name: Lactulose Classification: Laxative Indication / Action Dosage & frequency rate Contraindication Adverse Reaction Nursing Consideration Constipation. and. Treatment of hepatic encephalopathy. 21-23    . chloride.

    Decrease viscosity of respiratory tract secretions Generic Name: Salbutamol Classification: Sympathomimetics Indication / Action Dosage & frequency rate Contraindication Should not be used against: Adverse Reaction This medication may cause:       CNS Stimulation GI Upset Hypertension Bronchospasm Sweating Pallor Flushing  Nursing Consideration Teach the client about the proper use of prescribe delivery system. emphysema Nebulizer every 8hours      Cardiac Disease Vascular Disease Diabetes Hyperthyroidism Pregnancy and Lactation Date started: Dec. character Assess patient·s respiration and pulmonary secretions. frequency. 20-28 Assess patients underlying condition. Bronchospasms chronic bronchitis.Generic Name: Acetylcysteine Classification: Expectorant Indication / Action Dosage & frequency rate Contraindication Adverse Reaction Nursing Consideration Treatment for respiratory affections characterized by thick and viscous hypersecretion: acute and chronic bronchitis and its exacerbation. axarcise caution on patients with respiratory insufficiency and history of bronchospasm.22-25 . cough: type. pulmonary emphysema and bronchiectasis. 18. 600mg Should not be used against:   Hypersensitivity phenylketonuria This medication may cause:    nausea and vomiting GI symptoms Generalized urticaria accompanied by mild fever Hypotension Wheezing Dyspnea stomatitis   Date started: Dec.

Dosage & frequency rate 100cc TIV q 8 Shifted to 75cc Contraindication Should not be used against:  Hypertensive to drug  Anuria  Severe pulmonary congestion  Pulmonary edema. Adverse Reaction This medication may cause:  Dizziness  Headache  fever Nursing Consideration assess patients blood ptressure monitor blood and blood pressure regularlty check weight monitor CNS symptoms and changes in mental status     . Provide small frequent meals to ensure adequate nutrition due to GI upset  500mg / tab BID Date started: Dec. into interstitial fluid and plasma. resulting in enhanced flow of water from tissues including the brain and cerebrospinal fluid. or increased intraocular pressure Elevates blood plasma.osmolality.cerebral edema. viral infection  diarrhea  concomitant use with any of the ff: -Cysapride -Pimozide -Terfenadine Adverse Reaction This medication may cause:  Abdominal Cramping  Anorexia  Diarrhea  Vomiting  Confusions  Uncontrollable Emotions Nursing Consideration Check culture and sensitivity test to see if this the drug of choice Monitor renal function decrease dose as needed Ensure that full course is given to help prevent emergence of strain. and maxillary infection. 19-20 Discontinued by: 29( 8am)    Generic Name: Mannitol Classification: Diuretic Indication / Action Reduction of elevated intracranial pressure.Generic Name: Clarithromycin Classification: Anti-infectives. Interfere with protein synthesis and altering them in bacteria Dosage & frequency rate Contraindication Should not be used against:  Allergy  to fungal. skin. sinus. Macroplides Indication / Action Treatment of various respiratory.

abdominal.Generic Name Ceftriaxone Classification: Anti-infective Ceophalosporin second generation Indication / Action Dosage & frequency rate Contraindication Should not be used against: Sepsis. meningitis. Provide small frequent meals to ensure adequate nutrition due to GI upset Nursing Consideration            . Respiratory tract infection 1g IV q 12  Shifted to Levofloxacin by Nov.12 For prophylaxis or infections Previous hypersensitivity to aspirin Anaphylactic Shock Severe renal and hepatic failure         GI Upsets Hematological changes Skin reactions Coagulation Disorders Phlebitis (IV administration) Headache Dizziness Renal and gallbladder precipitation Increase In liver enzyme Oliguria Increase serum creatinine Anaphylactoid reaction Chill Cyanosis in infants Adverse Reaction This medication may cause:  Check culture and sensitivity test to see if this the drug of choice Monitor renal function decrease dose as needed Ensure that full course is given to help prevent emergence of strain.

Dosage & frequency rate 500mg 1 tab Contraindication Should not be used against:  Hypersensitivity Adverse Reaction This medication may cause:  URTI. Contraindication Should not be used against:   Impaired kidney or liver Sensitivity to the drug Adverse Reaction This medication may cause:   Skin rashes and other allergic reaction.  Nursing Consideration Do not take other drugs containing acetaminophen without medical advice over dosage and chronic use can cause hepatic damage and other toxic effect Generic Name: Irbesartan Classification: Cardiovascular drug. Angiotensin II Antagonist Indication / Action Competitively block the angiotension AT1 receptor located in vascular smooth muscle and the adrenal glands. mild to severe pain. fatigue. GI disturbances. cough. dyspepsia/heartburn.Generic Name: Paracetamol Classification: Antipyretic Indication / Action Dosage & frequency rate 500mg 1 tab For fever. Mat take with or without food Continued by: Dec. 20-29 . diarrhea  Nursing Consideration Take only as directed.

this is a technical inaccuracy).e. though it is said to be isotonic with blood in clinical contexts. . >Correct solution. >Replacement & maintenance of fluid & electrolytes. No net fluid shifts occur between isotonic solutions because the solutions are equally concentrated. NS contains 154 mEq/L of Na+ and Clï) Isotonic solution expands intracellular and extracellular space equally. Uses: intravenous drips (IV·s). (20cc/kg of lean body weight for hypovolemi c hypotensio n) >Monitor pt. Signs of infiltration / sluggish flow b. Nonetheless. Pulmonary Edema 1000 ml 1L @ 25 gtts/min. the osmolarity of normal saline is a pretty close approximation to the osmolarity of NaCl in blood. frequently for: a. for patients who cannot take fluids orally and have developed or are in danger of developing dehydration or hypovolemia Severe HPN. Dwell time of catheter and need to be replaced d.9% Sodium Chloride Solution] -Isotonic volume expander -Electrolyte replacement Sodium ² 154 mmol Chloride ² 154 mmol (NS is 9g NaCl dissolved in 1 liter water. more solute per litre) than blood (hence.IV FLUID STUDY TYPE OF SOLUTION CLASSIFICATION CONTENT MECHANISM OF ACTION INDICATION CONTRAINDICATION HOW SUPPLIED DOSE NURSING RESPONSIBILITIES Plain Normal Saline Solution (PNSS) [0. >Check and regulate the drop rate. Signs of phlebitis / infection c. Condition of catheter dressing >Check the level of the IVF. medication and volume. Change the IVF solution if needed. It has a slightly higher degree of osmolarity (i.

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Maintain or muscle control OBJECTIVE: Limited ROM Body weakness Decreased motor activity Inability to perform action as instructed . Turn and position the patient every 2 hours to promote circulation to all tissues and relieves pressure. Perform passive assistive ROM exercises to affected extremities to promote venous return and maintain muscle strength.NURSING CARE PLAN ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION UBJECTIVE: ´ hindi siya makagalaw simula ng mastoke siyaµ as verbalized of her wife. Encourage appropriate use of assistive device such Long term: After 4 days of nursing intervention. Participate in the interventions rendered by the nurse by being active in every activities that they have 2. Short term: After 8 hrs of nursing intervention. Participate in the interventions rendered by the nurse 2. walker. client will be able to: 1. Maintain skin integrity 4. client was able to physical mobility Short term: After 8 hrs of nursing intervention. Maintain skin integrity 4. Assess patient·s ability to perform ADLs effectively using Functional Level Classification. 3. Impaired physical mobility r/t neuromuscular damage involvement as evidence d by decreased motor activity Long term: After 4 days of nursing intervention. and wheelchair to increase mobility. client was able to: 1. client will be able to mobility physical 1. Demonstrate resumption of activities 3. 4. 2. Maintain or muscle control as crutches. Demonstrate resumption of activities by performing it 3.

the client will be able to maintains optimal tissue perfusion to vital organs. 2. the client will be able to maintains optimal tissue perfusion to vital organs. Short-Term: After 4 hours of nursing intervention. the client will be able to : 1.ASSESSMENT SUBJECTIVE: ´Napansin ko na lagi nalang may dinadaing na masakit na hindi alam ang dahilan. 5. as evidenced by strong peripheral pulses. 3. Participate in passive ROM. Avoid measures that may trigger increased ICP such as straining. and INTERVENTION 1. and strenuous coughing. Long Term: EVALUATION After 8 hours of nursing intervention.Recognize regarding some measures to prevent increase ICP. Monitor the respiratory status.µ As verbalized by the patient·s wife. Instructed to exhale through the mouth during voiding or defecation to decrease strain. the client will be able to : 1. . alert LOC. DIAGNOSIS Ineffective tissue perfusion r/t vasoconstriction of blood vessels PLANNING Long Term: After 8 hours of nursing intervention. normal ABGs. Exercise breathing pattern during defecation and voiding. as evidenced by strong peripheral pulses. Elevate head of bed 3045° if increase ICP. 3. alert LOC. 2. and absence of chest pain OBJECTIVE: Confused Altered LOC Lethargic Increased ICP (BP: 160/100) (+) facial grimace absence of chest pain Short-Term: After 4 hours of nursing intervention. 3.Recognize regarding some measures to prevent increase ICP. 4. normal ABGs. 2. Perform passive range-ofmotion (ROM) exercises to unaffected extremity every 2 to 4 hours to prevent venous stasis. Exercise breathing pattern during defecation and voiding. Participate in passive ROM.

OBJECTIVE: Difficulty Short-Term: After 2 hours of nursing intervention. gestures or demonstration. the patient was able to: 1. R: It EVALUATION Long-Term: After 1 hr. Facial paralysis. Place important objects within reach. Reduce anxiety 3. R: This maximizes patient·s sense of independence. the patient will establish method of communication in which needs can be expressed. Talk directly to patient. producing speech. Maximize sense of independence.   reduces confusion or anxiety 3. R: It is important for family members to continue talking to the patient to reduce patients isolation. Provide alternative methods of communication. . 5. 3. Lessen the feeling of being isolated. Speaking slowly and directly. Decrease frustrations. Use yes or no question to begin with. Utilized non-verbal cues as a form of communication. 5. Instruct the family members to give ample time talking to the patient. INTERVENTION 1. Reduce anxiety. like pictures or visual cues. 4. Maximize sense of independence.ASSESSMENT SUBJECTIVE: ´ Napansin ko sa asawa ko na pautal-utal n magsalita at hindi ko na naiintndihan ang sinasabiµ as verbalized by the patientµs wife. Utilize non-verbal cues as a form of communication. R: Helpful in decreasing frustration 4. R: Provide communication needs. Decrease frustrations. 2. Anticipate and provide for patient·s needs. 2. Lessen the feeling of being isolated. DIAGNOSIS Impaired verbal communication related to loss of facial or oral muscle tone control. the patient will be able to: 1. 5. of nursing intervention. Muscle and     facial tension. Short-Term: After 2 hours of nursing intervention. 2. PLANNING Long ²Term: After 6 hours of nursing intervention. 4. the patient was able to establish method of communication in which needs can be expressed.

the client will be able to display improvement in wound healing INTERVENTION 1. the client will be able to: 1. wala n siyang gnwa kundi ang humiga ng humiga. PLANNING Long-term: After 8 hours of nursing intervention. Encourage the patient to increase fluid intake to lessen the skin breakdown. Encourage the client to utilize lift sheets to reduce shearing forces of the skin After 4 hours of nursing intervention.µ As verbalized of the patient·s wife DIAGNOSIS Impaired skin integrity r/t physical immobilization as evidence by hemiparesis. Reduce shearing forces of the skin. 2. (any T. the client was able to: 1. Reduce shearing forces of the skin AEB turning the client side to side. Lessen skin breakdown. the client was able to display improvement in wound healing Short term: Objective: -Limited ROM -Dry cracked skin After 4 hours of nursing intervention. 3. preferably cotton fabric Short term: Long-term: EVALUATION After 8 hours of nursing intervention. 2. dry clothes. . Instructed family to maintain clean. Encourage implementation and posting of a turning schedule. limited ROM and dry skin. 4.ASSESSMENT Subjective: ´Simula nang maparalize siya.shirt). Lessen skin breakdown 2. restricting time in one position to 2 hours or less.

Provide oral care after meals. the client will be able to: 1. prevent from aspiration 2. Long-Term: After 2 hours of nursing intervention the client was able to: Maintain a patent airway and clear lung sounds by discharge. Short term: After 4 hours of nursing intervention. 4.ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION 1. Monitor level of Sujective: ´Sa tuwing pinapakain ko na siya lagi siyang nahihirapan lumunok. After 4 hours of nursing intervention. the client will be able to maintain a patent airway and clear lung sounds consciousness to prevent risk for aspiration. prevent from aspiration 2. the client was able to: 1. Assess gag and cough reflex to prevent risk for aspiration. Encourage patient to chew thoroughly and eat slowly Short term: Objective: Pt exhibits difficulty swallowing without choking. 2. Risk for aspiration r/t impaired swallowing Long Term: After 8 hours of nursing intervention. 3. position properly during eating . position properly during eating during meals. 5. Instruct patient not to talk while eating.µ As verbalized of the patient·s wife.

she noticed that her husband had a right sided upper extremity weakness and a slurred speech. 2010 at 12:25 pm. History of Present Illness Patient had CVA 4 years ago with right sided weakness. The working diagnosis for him was CVA infarct.dry skin. maintained with Amlodipine. Symmetrical lung expansion was noted along with adynamic precordium. he had a TB during his childhood. He was given Nifedipine by his daughter. Ranitidine 50mg IV. which caused him to have a temporary loss of memory or amnesia. Patient has hypertension in the past.COURSE IN THE WARD History of Past Illness According to the patient·s daughter. He also had a gunshot wound on his left thigh when he was about 30 years old. pink palpebral conjunctiva. Patient is an alcohol drinker along smoking. The patient was instructed to be on NPO temporarily and on HBR position. patient had the ff. 1tab to be . Currently. rough. The doctor also ordered for some lab workups like CBG. Main CT scan. Na. Aspirin 80mg 1tab. He was also involved in a bus accident at year 2002. Family also have hypertension. O2 via NC at 4 lpm. slurring of speech. One day prior to admission. K. Doctor ordered IVF of PNSS 1L to run for 16 hours. he has pneumonia and his wife. medications: Citicholine 2gm TIV now then 1gm BID. Chief complaint was dizziness. anicteric sclera. UA. Patient has normocephalic head. ER (11/07/10) Patient X was admitted to the ED last November 07. BUN. Crea. CXR. when his wife arrived home. that the patient be admitted to ED. He also had a surgery on his left leg due to the accident. V/S was to be monitored every 1 hour along with his I&O. Some part of the extemitites is swelling.

The doctor also ordered that the patient be admitted to the MMW in service of Dra. Lactulose 30cc q HS. CT scan was prompted. . Deleon/ Dr. Nebulization instructed. Irbesartan 150g 1 tab OD. Client was ordered to be turned from side to side every 2 hrs. Ceftriaxone 1gm IV q12 ANST. Client was instructed to have LSLF diet as ordered. he was awake and coherent. Patient·s family refused NGT insertion with consent signed and secured. Furosemide 40g IV now.chewed and swallowed. CT scan result and kept rested (11/11/10). Similar interventions were carried out through the days. Citicholine 1gm IV q 12. He was put on clear liquid diet. Instructed the client to have LSLF diet as ordered. and be placed on MHBR. Lim/ Dr. IVF was maintained and O2 support via NC at 3lpm. NGT was ordered to be inserted and start OF feeding at 1600 kcal in 6 divided using nutren optimum at 3:50pm MMW (11/08/10) Patient was admitted to the male medicine ward accorging to the doctor·s order . Follow up of CXR. mannitol was ordered to be decreased to 45cc TIV every12 hrs. For relay CXR. Doctor asked that a secured consent to admission and management. for 2 doses then discontinue(11/10/10). Prescribed medications were followed accordingly. Doctor ordered to Shift cefriaxone to levofloxacin 1 tab OD and clindamycin 300mg 1 cap QID (11/12/10). (11/09/10 ² 11/29/10) Care and management is continued to the patient who have ongoing IVF of PNSS 1L to run for 10 hrs. Clarithromycin 500mg.. on MHBR. Increase irbesartan to 300mg 1 tab OD (11/13/10). teodocio.

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

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

Treatment  Explain the purpose of treatment and why it is continued at home.  Explain with them the advantages and disadvantages of strict compliance of treatment regimen. This will help the family and the patient to know the importance and advantage in complying treatment regimen.  Instruct the patient not to skip taking medications and complete the whole course of medication.  Remind them to take the drugs properly and taking note of the expiration date before taking the medication. This will ensure and encourage the patient that taking medications will help treat and prevent recurrence of the disease and for faster recovery  Instruct the patient and whether the right time. This will prevent accidents of drug poisoning.  Instruct and warn patients and significant other about the possible effects and adverse reactions that may occur brought about by taking the medications. This will help for an effective action and compliance of the medications and for faster recovery. Exercise/Environment  Encourage the client to exercise ROM.  Instruct the patient and the family to properly store and handle the medications so as to let children accidentally get hold of it. This will ensure good compliance of the medications to be taken and to prevent accident poisoning. This will prevent further complications and unnecessary effects to the patient.DISCHARGE PLANNING Medication  Discuss with the patient the need to comply with home medication. right dosage. right medication.  Remind the patient about the importance of taking consideration of the foods and other drugs that is contraindicated while taking the medications. This will avoid confusion of the proper drugs that would be taken by the patient. This will help the patient and family to be oriented about the treatment and this will help him understand about the importance of taking the prescribed drugs for faster . and right routes as ordered by the physician.

To prevent having elevated blood pressure. Diet  Encourage the client to be on low salt low fat. To promote good health and prevent infection. Health Teaching/Hygiene  Encourage and advice the patient and family members practice proper handwashing before and after eating. To monitor health status and conditions. . It also increases the sense of wellness.  Direct and instruct the patient and the family to give medication or assist the patient according to the medication regimen.  Emphasize the importance of recognizing any sign of unusuality. Out-patient Referral  Encourage the patient and the family to have regular check-up with their physician. Also. To immediately give enough attention to treat the said complaint. 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.  Instruct patient to do activities of daily living if the client is able to do. Following the doctor·s order and complying will help achieve the success of the treatment coarse and will help for the immediate recovery of the patient. Proper handwashing will prevent the spread of infection.  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. which is very much needed in the therapeutic process. To give appropriate intervention. This will help recognize any alterations in the body.  Encourage the patient and the family to immediately report any unusualities regarding the patient·s condition.recovery in the disease process. to make them aware that the treatment is not only done in the hospital but it should be continued at home.