RLE – MODULE

Course Code NCM 104

Course Title Care of clients with problems in Inflammatory and Immunologic Response
and Perception and Coordination
Level Offering 1st Semester AY 2020-2021
Clinical area of assignment Medical Ward
Date of Exposure September 7-9, 2020
No. of hours 24 hours

CASE STUDY

CONGRATULATIONS! For you are a few steps away of pursuing your dream of becoming a “nurse”.

Remember: ‘The Way to Get Started Is to Quit Talking and Begin Doing.” – Walt Disney

INSTRUCTIONS:
Read the case of a patient whom you are to provide nursing care. Take time to analyze and process the
information provided, before answering the activities following each section of your module.
You may take a break, as necessary. You can ask your friends, classmates, parents, or any person whom
you think can help you understand but remember a greater amount of output should come from you, as
you are the LEARNER here.
Of course, you can ask me, your clinical instructor, for clarification on areas you do not seem to understand
and do not know what to do. Would be thankful and gladly help you on your learning needs. You can
contact me through my number Messenger/ Mobile number/ Email address at ___________________.

For you to conduct all the requirements for this rotation, we may follow the schedule below:
Online:
Day 1: AM: read on your patient’s case and answer the given activity. In the
afternoon we shall process 1 nursing problem (actual).
Day 2: AM: processing of 2nd nursing problem (actual/potential), PM – partial or full
processing of concept map
Day 3: AM: processing of concept map if not yet done, PM – rotational exam (20
points)
Modular: Remember that you are given 3-5 days to finish this task.

ENDORSEMENT: You are on duty in the medical ward at 7- 3 shift to a male patient

Endorsing a male client, 54 y/o, at bed 9.

▪ With an IVF of 0.45% Normal Saline Solution 1 liter x KVO @ 750cc level.
▪ With an O2 at 2LPM via NC
▪ On NGT with special diet
▪ No bathroom privileges
▪ Monitor I & O
▪ Monitor vital signs q 1⁰
▪ V/S as follows: T – 36.7 °C PR – 62 BPM RR– 24 BP – 140/90mmHg
SP02- 90%

Patient’s Profile:
Name: Patient X
Age: 56
Sex: Male
Civil status: Married
Address: Kin- iway, Besao, Mountain Province
Occupation: Farmer
Nationality: Filipino
Religion: Anglican
Date and time of Admission: September 6, 2020; 6:25 am
Ward & Bed no. Medical ward, bed 6
Admitting Diagnosis: CVD, probably pontine area, HPN Stage II
Chief complaints: Loss of consciousness
Final diagnosis: CVD, Hemorrhagic left thalamic, left cerebral peduncle and Pons with
intra ventricular extension.
HISTORY OF PRESENT ILLNESS:
⮚ Two days prior to admission, early in the morning, September 03, 2020, the patient’s wife noticed that
her husband is unresponsive, irregular respirations with pauses at the end of inspiration and expiration,
unconscious and no reactions at all to any types of stimuli. Therefore, the wife immediately brought her
husband into the nearest hospital by the use of the police car in their barangay since they don’t have
the means to transport and hence admitted. Upon arrival, a plain CT scan was conducted and done at
the hospital, Veterans’ Regional Hospital. The wife decided to transfer the patient at Baguio General
Hospital and Medical Center for more consistent care and proper treatment. Official CT scan reading
shows an acute haemorrhage at the center thalamus extending to the left cerebral peduncle and pons.

PAST MEDICAL AND SURGICAL HISTORY:

⮚ The patient had a traumatic car accident way back year 2005. He had undergone a laser operation of
kidney stone at St. Lukes Medical Center, Quezon City at the year 2007. He was first diagnosed with
cerebro vascular disease at year 2016. Upon interviewing his wife, she said that her husband only
encountered fever, headache, cough and colds these past months. No known allergies.

FAMILY HISTORY:
⮚ According to his wife, the patient’s parents died due to stroke and cardiac problems. His older brother
died due to cardiac arrest. His family also has a history of diabetes and hypertension.

SOCIAL, ENVIRONMENTAL AND HEALTH HISTORY:

ACTIVITY 1: Underline using a red pen the pertinent positive and negative data or findings that
you think are relevant in the formulation of your nursing diagnoses

FEEDBACK: Congratulations! You can now proceed with the activity.

Note: Can also be given through text

PHYSICAL EXAMINATION & REVIEW OF SYSTEMS

- Focused assessment on the organs/system affected and state pertinent findings
appropriately (+/-)
General Survey Laser operation of kidney stone (+)
Skin Cold clammy (+) pale (+), edema (-)
Head, Eyes, Ears, Nose, Head: masses indentation and skin breakdown on scalp (-), infestation (-
Throat ), weak temporal pulse, PERRLA: uneven size or shape, non-reactive to
light or accommodation,, Ear: masses (-), mastoid masses (-), tympanic
membrane normal eardrum. Nose: No septum deviation noted. Mouth:
lesions (-), dental caries (-), gag reflex (-).
Neck Lump or gorder (-), jugular vein distention (-), hard lymph nodes (-),
carotid artery distention (-) with weak thread pulse.
Breast Mass or lump (-).
Respiratory Hx of cough (+) and colds (+), wheezing (-), SOB (+), hx of nocturnal
dyspnea (+)
Cardiovascular Peripheral pulse (+), neck vein distention (-), HR irregular and weak,
thorax in normal shape, masses (-), heart sounds clear but weak, faint
murmur between S1 and S2 (+), chestpain (-), tachycardia (-), palpitation
(-), dyspnea (-), pink-tinged sputum (-),
Gastrointestinal Bower sounds (+), ABD is soft and nontender , Appetite (-), flatulence (+),
Epigastric discomfort and pain (-), NV (-), diarrhea (-), constipation (-)
Urinary Nocturia (-),
Genital ulcerations(-), scars(-), nodules(-), signs of inflammation(-), lump (-),
swelling(-), masses(-)
Peripheral / Vascular Peripheral cyanosis (-), peripheral pallor (+), tar staining (-),Xanthomata
(+), gangrene (-), capillary refill time (CRT) of 5 sec.,
Musculoskeletal Assisted passive ROM (2), sternoclavicular swelling or redness (-)joint
tenderness (-), cervical and lumbar spine are concave, thoracic spine is
convex, spine is straight when observed from behind, Upper extremities
and lower extremities symmetric, lesions (-), nodules (-), deformities (-),
Neurologic Headache(+), seizure (-), dizziness (+), lightheadedness (+), numbness
and tingling sensation (+), difficulty speaking (+), difficulty swallowing (-),
bower movement (+), bladder control (-)muscle weakness of loss of
movement (-), involuntary trembling, quivering, shaking, or other
movements (-), memory loss (-),
Hematologic Episodes of bleeding (-), rash (-), ecchymoses (-), hematuria (-),
proteinuria (-),
Endocrine Fatigue (+), weight loss (-) excess hair growth (-), decreased muscle
mass (-), irritability (+). Excessive sweating, anorexia (-)
Psychiatric Disorientation (+), Appetite (-), suicidal ideas or intentions (-), psychosis
(-), hallucinations (-), delusions (-), long lasting sadness (-), social
 withdrawal (-), insomnia (-), manina (-),

ACTIVITY 2: Recalling the concepts of health assessment, anatomy and physiology, you have to
identify at least FIVE pertinent PE findings that shows abnormality. Read your books or notes for
you to elaborate on the cause of your patient’s clinical signs and symptoms. In your own words,
explain the condition by summarizing what you have read or understood, this is highly encouraged.
You must also supply the textbooks or materials that you have utilized as references.

PERTINENT ABNORMAL EXPLANATION

PE/ROS
1.
2.
3.
4.
5.
Reference/s:

FEEDBACK: You might find it easier, if you have your textbooks with you. Congratulations! You
can now proceed with the activity.

DIAGNOSTIC STUDIES:

ACTIVITY 3: Using a reference book (specify), you have to fill in the values that are asked.
Indicate the appropriate rationale for the diagnostic test done, its purpose, the abnormality and/or
nursing intervention needed.
Laboratory test & Reference/nor Result Interpretation What have caused
Pertinent Laboratory mal values the abnormality/
Result Purpose/NI
1. Complete Blood
Count

RBC Male adult: 4.5 3.5 million/mm3 Low Acute or chronic

– 6.2 bleeding lowers the
million/mm3 RBC in the system.
Female adult:
4.5 – 5.0
million/mm3

Hemoglobin(Hgb) Male: 14-16.5 14g/dL Normal

g/dL
Female: 12-15
g/dL

Hematocrit Male: 42 – 43% Normal

52%
Female: 35 –
47%
Platelets 150,000 to 250,000 Normal
400,000 cells/mm3
cells/mm³

4,500 to 9,000/mm3 Normal

WBC Differential 11,000
cells/mm³ of
WBCs

3,200/mm3 Normal
20–0% (1000–
Lymphocytes 4,800/mm3)

2-8% (0– 400/mm3 Normal

Monocytes 800/mm3)

1-4% (0– 400/mm3 Normal

Eosinophils 450/mm3)
 2-2% or 0.0- 600/mm3 Normal
Basophils 700/mm3

2. Electrolyte
Serum
Sodium 135-145 mEq/L 140mEq/L Normal

Potassium 3.5-5.0 mEq/L 3.7 mEq/L Normal

Chloride 98-106 mEq/L 101 mEq/L Normal

Normal
Bicarbonate 22-29 mEq/L 25 mEq/L

Calcium 4.5-5.5 mEq/L 5.1 mEq/L Normal

or
8.5-10.5 mg/dL

Phosphorus 1.8-2.6 mEq/L 1.7 mEq/L Normal

or
2.7-4.5 mg/dL

Magnesium 1.6-2.6 mg/dL 1.9 mEq/L Normal

Less than Borderline High

3. Cholesterol 200mg/dL 310 mg/dL Borderline Cholesterol
High indicates a high
cholesterol
particularly LDL
High-density 30-70 mg/dL 25 mg/dL Slightly Low and triglycerides
lipoprotein (HDL) which contributes
to building up in the
arteries and lead to
Low-density Less than 130 160 mg/dL Borderline serious health
lipoprotein (LDL) mg/dL High problems. These
deposits will make
it difficult for
Triglycerides Less than 170 mg/dL Borderline enough blood to
150mg/dL High flow through
arteries. This could
cause problems
throughout the
body, particularly in
your heart and
brain, or it could be
fatal. This is the
main culprit of
atherosclerosis, a
primary cause of
cerebrovascular
disease (CVD).
Clotting is what
prevents excessive
bleeding when you
4. Coagulation cut yourself. But
Studies the blood moving
through your
vessels shouldn’t
Prothrombin time (PT) Varies 12 secs Normal clot. If such clots
(compare with form, they can
control), travel through your
 11–13 sec bloodstream to
your heart, lungs,
or brain. This can
Varies cause a heart
Partial thromboplastin (compare with attack, stroke, or
time (PTT) control): 29 secs Normal even death.
25–35 sec Coagulation tests
measure your
Varies blood’s ability to
Thrombin time (TT) (compare with 8 secs Normal clot, and how long
control), it takes to clot.
8–11 sec Testing can help
your doctor assess
170–340 your risk of
Fibrinogen mg/100 mL excessive bleeding
180 mg/mL Normal or developing clots
(thrombosis)
20–40% somewhere in your
(1,500– blood vessels.
5,500/mm3)

FEEDBACK: That’s the spirit keep going.

You might want to have a few minutes break before proceeding to the areas of the module.

MEDICAL/SURGICAL DIAGNOSIS:

ACTIVITY 4: Read about your patient’s diagnosis using your textbook (MedSurg/ specify). Focus
on the description of the disease, the etiology or cause, what are the signs and symptoms and why
do they occur, what are the recommended interventions and nursing interventions. Digest the
information that you have obtained. Take time to process and analyze them. Once you are ready,
in 500 words or briefly answer the following questions.

Signs & Signs & symptoms

Description of the Disease Etiology Symptoms (patient)
(book)
CVD, Hemorrhagic left Cerebrovascular Numbness or  unconscious
thalamic, left cerebral disease develops for a weakness of the
peduncle and Pons with variety of reasons. face, arm, or leg,
intra ventricular extension. There are several especially on
causes like one side of the
Intracerebral body
hemorrhage, • Confusion or
subarachnoid change in
hemorrhage, cerebral mental status
aneurysm, • Trouble
arteriovenous speaking or
malformation. If understanding
damage occurs to a speech
blood vessel in the • Visual
brain, it will not be able disturbances
to deliver enough or • Difficulty
any blood to the area of walking,
the brain that it serves. dizziness, or
The lack of blood loss of balance
interferes with the or coordination
delivery of adequate • Sudden severe
oxygen, and, without headache
oxygen, brain cells will  a severe and
start to die. Brain sudden
damage is irreversible. headache
Emergency help is vital  paralysis of
to reduce a person’s one side of
risk of long term brain the body, or
damage and increase hemiplegia
their chances of  weakness on
survival. one side,
Atherosclerosis is a also known
primary cause of as
cerebrovascular hemiparesis
disease. This occurs  losing vision
when high cholesterol on one side
levels, together with  becoming
 inflammation in the unconscious
arteries of the brain,
cause cholesterol to
build up as a thick,
waxy plaque that can
narrow or block blood
flow in the arteries.
This plaque can limit or
completely obstruct
blood flow to the brain,
causing a
cerebrovascular attack,
such as a stroke or TIA.
Reference: Reference/s: Health Assessment in Nursing by Janet R. Weber,
Brunner & Suddarth’s Medical Surgical Nursing, Tortora’s Principle of
Anatomy & Physiology, http://www.learningradiology.com/,
https://nursing.uworld.com/nclex-rn/, https://www.medscape.com/

FEEDBACK: KEEP UP THE GOOD WORK! What you are doing will keep you focused and enable
to understand your patient the best way possible. It may be hard on you at the start but doing it
often, you will soon find it easier. Remember, NO PAIN! NO GAIN.

PRESCRIBED THERAPEUTIC (MEDICAL/SURGICAL) MANAGEMENT, AND HEALTH PROMOTION

PROGRAMS:

Activity 5: After reading your textbook or notes on pharmacology and/or med-surgical books,
answer what are asked on the following table.
Drug/ Dose/Route/ Mechanism of Common Side Nursing
Classification Frequency action Effects responsibilities
10–80 mg/day Inhibits HMG-CoA M Myalgia, BASELINE
1. Atorvastatin reductase, an early myopathy, ASSESSMENT
(Lipitor) 9and rate-limiting) rhabdomyolysis, Question for possibility of
Therapeutic step in cholesterol headache, chest pregnancy before initiating
class:Antilipe biosynthesis. May pain, peripheral therapy (Pregnancy
mics interact with edema, dizziness, Category X). Assess
Pharmacologi CYP3A4 inhibitors rash, abdominal baseline lab results:
c class: HMG- (e.g., amiodarone, pain, constipation, cholesterol, triglycerides,
CoA diltiazem, diarrhea, hepatic function tests.
reductase cyclosporine, dyspepsia, nausea, Obtain dietary history.
inhibitors grapefruit juice) flatulence,
increasing risk of increased hepatic INTERVENTION/EVALUA
myopathy. function TION
tests, back pain, Monitor for headache.
sinusitisay interact Assess for rash, pruritus,
with CYP3A4 malaise. Monitor
inhibitors (e.g., cholesterol, triglyceride
amiodarone, lab values for therapeutic
diltiazem, response.
cyclosporine, Monitor hepatic function
grapefruit juice) tests, CPK.
increasing risk of PATIENT/FAMILY
myopathy. TEACHING
• Follow special diet
(important part of
treatment). • Periodic lab
tests are essential
part of therapy. • Do not
take other
medications without
consulting physician.
• Report dark urine,
muscle fatigue, bone
pain. • Avoid excessive
alcohol intake,
large quantities of
grapefruit juice.
Atherosclerosis, Inhibits HMG-CoA Generally well BASELINE
2. Lovastatin Coronary Artery reductase, the tolerated. Side ASSESSMENT
(Altoprev, Apo- Disease enzyme effects usually Obtain dietary history.
Lovastatin, PO: ADULTS, that catalyzes the mild and transient. Question for possibility
Mevacor, Novo- ELDERLY: Initially, early step in Frequent (9%– of pregnancy before
Lovastatin ) 20 mg/day. cholesterol 5%): Headache, initiating
PHARMACOTHE Maintenance: 10– synthesis. flatulence, diarrhea, therapy (Pregnancy
RAPEUTIC: 80 mg once daily or Therapeutic Effect: abdominal Category X). Assess
HMG-CoA in Decreases pain, abdominal baseline lab results:
reductase 2 divided doses. LDL, VLDL, cramping, serum cholesterol,
inhibitor. Maximum: 80 triglycerides; rash, pruritus. triglycerides, hepatic
CLINICAL: mg/day. increases Occasional (4%– function tests.
Antihyperlipidemi Hypercholesterolem HDL. 3%): Nausea, INTERVENTION/EVALUA
c ia vomiting, TION
PO: ADULTS, constipation, Monitor daily pattern of
ELDERLY: Initially, dyspepsia. bowel activity,
20 mg/day. Rare (2%–1%): stool consistency. Monitor
Maintenance: 10– Dizziness, for headache,
80 mg once daily or heartburn, myalgia, dizziness, blurred vision.
in blurred vision, eye Assess for rash,
2 divided doses. irritation. Potential pruritus. Monitor serum
Maximum: 80 for cataract cholesterol, triglycerides
mg/day. development. for therapeutic response.
PO (Extended- Occasionally Be
Release): ADULTS, produces myopathy alert for malaise, muscle
ELDERLY: manifested as cramping/weakness.
Initially, 20–60 mg muscle pain, Monitor hepatic function
once daily at tenderness, tests.
bedtime. Maximum: weakness with PATIENT/FAMILY
60 mg once daily at elevated creatine TEACHING
bedtime. kinase (CK). Severe • Follow special diet
Heterozygous myopathy (important part of
Familial may lead to treatment). • Periodic lab
Hypercholesterolem rhabdomyolysis. tests are essential
ia part of therapy. • Avoid
PO: CHILDREN grapefruit juice,
10–17 YRS: alcohol. • Inform physician
Initially, 10 mg/ of severe gastric
day. May increase upset, vision changes,
to 20 mg/day after 8 myalgia, weakness,
wks changes in color of
and 40 mg/day after urine/stool, yellowing
16 wks if needed. of eyes/skin, unusual
Dosage with bruising.
Concurrent
Medication
Cyclosporine:
Initially, 10 mg/day.
Maximum:
20 mg/day.
Fibrates, niacin (1
gram or more):
Maximum: 20
mg/day.
Amiodarone,
verapamil:
Maximum:
40 mg/day
(immediate
release); 20 mg/
day (extended
release).
Hypertension Suppresses renin- Frequent (7%–4%): BASELINE
3. Captopril PO: ADULTS, angiotensin- Rash. Occasional ASSESSMENT
kap-toe-pril (Apo- ELDERLY: Initially, aldosterone (4%–2%): Pruritus, Obtain B/P immediately
Capto , Capoten 12.5–25 system (prevents dysgeusia (altered before each dose,
,Novo-Captoril ) mg 2–3 times a conversion of taste). Rare (less in addition to regular
PHARMACOTHE day. After 1–2 wks, angiotensin than 2%): monitoring (be alert
RAPEUTIC: may I to angiotensin II, Headache, to fluctuations). If
Angiotensin- increase by 12.5– a potent cough, insomnia, excessive reduction in
converting 25 mg/dose. vasoconstrictor; dizziness, fatigue, B/P occurs, place pt in
enzyme (ACE) Diuretic may inhibit paresthesia, supine position
inhibitor. may be added if no angiotensin II malaise, nausea, with legs elevated. In pts
CLINICAL: response in at local vascular diarrhea or with prior renal
Antihypertensive, additional and renal sites). constipation, dry disease or receiving
vasodilator 1–2 wks. If taken in Decreases mouth, tachycardia. dosages greater than
combination plasma Excessive 150 mg/day, urine test for
with diuretic, may angiotensin II, hypotension (“first- protein by dipstick
 increase to 100– increases dose syncope”) method should be made
150 mg 2–3 times a plasma renin may occur in pts with first
day after 1–2 wks. activity, decreases with CHF and in urine of day before
Maintenance: aldosterone those who are therapy begins and
25–150 mg 2–3 secretion. severely sodium/ periodically thereafter. In
times a day. Therapeutic Effect: volume depleted. pts with renal
Maximum: 450 Reduces Angioedema impairment, autoimmune
mg/day. peripheral arterial (swelling disease, or taking
CHILDREN: 0.3– resistance, of face/tongue/lips), drugs that affect
0.5 mg 3 times a pulmonary hyperkalemia occur leukocytes or immune
day. Maximum: 6 capillary wedge rarely. response, CBC should be
mg/ pressure; improves Agranulocytosis, performed before
kg/day in 2–4 cardiac output, neutropenia may be beginning therapy, q2wks
divided doses. exercise tolerance. noted in those with for 3 mos,
INFANTS: collagen vascular then periodically
0.15–0.3 disease thereafter.
mg/kg/dose. May (scleroderma, INTERVENTION/EVALUA
titrate up to systemic lupus TION
maximum of 6 erythematosus), Assess skin for rash,
mg/kg/day in 1–4 renal impairment. pruritus. Assist with
divided Nephrotic ambulation if dizziness
doses. Usual range: syndrome may be occurs. Monitor
2.5–6 mg/kg/day. noted in those urinalysis for proteinuria.
NEONATES: 0.01– with history of renal Assess for anorexia
0.1 mg/kg/dose q8– disease. secondary to altered taste
24h. perception.
Maximum: 0.5 Monitor serum potassium
mg/kg/dose q6– levels in
24h. those on concurrent
CHF diuretic therapy.
PO: ADULTS, Monitor B/P, BUN, serum
ELDERLY: Initially, creatinine,
6.25–25 CBC. Discontinue
mg 3 times a day. medication, contact
Target dose: 50 mg physician if angioedema
3 (swelling of
times/day. face, lips, tongue) occurs.
Post-MI PATIENT/FAMILY
PO: ADULTS, TEACHING
ELDERLY: Initially, • Full therapeutic effect of
6.25 mg, B/P reduction
then 12.5 mg 3 may take several wks. •
times a day. Skipping doses
Increase to or voluntarily discontinuing
25 mg 3 times a drug may
day over several produce severe rebound
days, hypertension.
up to 50 mg 3 times • Limit alcohol. • Notify
a day over several physician if swelling
wks. of face, lips, or tongue,
Diabetic difficulty
Nephropathy, breathing, vomiting,
Prevention of diarrhea, excessive
Renal Failure perspiration, dehydration,
PO: ADULTS, persistent
ELDERLY: 25 mg 3 cough, sore throat, fever
times a occur. • Inform
day. physician if pregnant or
Dosage in Renal planning to become
Impairment pregnant. • Rise slowly
Creatinine from sitting/
clearance 10–50 lying position.
ml/min:
75% of normal
dosage. Creatinine
clearance less than
10 ml/min: 50%
of normal dosage.
Chronic Stable Inhibits calcium ion Frequent (10%– BASELINE
4. Nicardipine Angina movement across 7%): Headache, ASSESSMENT
(Cardene, PO: ADULTS, cell membranes, facial flushing, Concurrent therapy of
Cardene IV, ELDERLY: Initially, depressing peripheral edema, sublingual nitroglycerin
Cardene SR) 20 mg 3 contraction light-headedness, may be used for relief of
times a day. Range: of cardiac, dizziness. angina pain. Record
20–40 mg 3 times a vascular smooth Occasional (6%– onset, type (sharp, dull,
day (allow 3 days muscle. 3%): Asthenia squeezing), radiation,
between dosage Therapeutic Effect: (loss of strength, location, intensity,
increases). Increases heart energy), duration of anginal pain,
Essential rate, cardiac palpitations, precipitating
Hypertension output. Decreases angina, tachycardia. factors (exertion,
PO: ADULTS, systemic Rare (Less Than emotional stress).
ELDERLY: Initially, vascular 2%): INTERVENTION/EVALUA
20 mg 3 resistance, B/P. Nausea, abdominal TION
times a day. Range: cramps, dyspepsia Monitor B/P during and
20–40 mg 3 times a (heartburn, following IV infusion.
day (allow 3 days indigestion, Assess for peripheral
between dosage epigastric pain), edema behind
increases). dry mouth, rash. medial malleolus. Assess
PO (Sustained- Overdose produces skin for facial
Release): ADULTS, confusion, slurred flushing, dermatitis, rash.
ELDERLY: speech, Question for
Initially, 30 mg twice drowsiness, marked asthenia (loss of strength,
a day. Range: hypotension, energy), headache.
30–60 mg twice a bradycardia. Monitor serum hepatic
day. enzyme results.
Short-Term Assess EKG, pulse for
Treatment of tachycardia.
Hypertension PATIENT/FAMILY
(Parenteral Dosage TEACHING
as Substitute for • May take without regard
Oral to food.
Nicardipine) • Sustained-release
IV: ADULTS, capsule taken whole;
ELDERLY: 0.5 do not break, chew, crush,
mg/hr (for pt or divide.
receiving 20 mg PO • Avoid alcohol, grapefruit
q8h), 1.2 mg/hr (for juice, limit caffeine.
pt receiving 30 mg • Inform physician if
PO q8h), 2.2 mg/hr angina pains
(for pt receiving 40 not relieved or
mg PO q8h). palpitations, shortness of
Pts Not Already breath, swelling,
Receiving dizziness, constipation,
Nicardipine nausea, hypotension
IV: ADULTS, occur. • Avoid tasks
ELDERLY requiring motor skills,
(GRADUAL B/P alertness until response
DECREASE): to drug is established.
Initially, 5 mg/hr.
May increase
by 2.5 mg/hr
q15min. After B/P
goal
is achieved,
decrease rate to 3
mg/hr.
ADULTS,
ELDERLY (RAPID
B/P DECREASE):
Initially, 5 mg/hr.
May increase by 2.5
mg/hr q5min.
Maximum: 15 mg/hr
until
desired B/P
attained. After B/P
goal
achieved, decrease
rate to 3 mg/hr.
Changing From IV
to Oral
Antihypertensive
Therapy
ADULTS,
ELDERLY: Begin
antihypertensives
 other than
nicardipine when IV
has been
discontinued; for
nicardipine, give
first
dose 1 hr before
discontinuing IV.
Dosage in Hepatic
Impairment
ADULTS,
ELDERLY: Initially,
give 20 mg
twice a day, then
titrate.
Dosage in Renal
Impairment
ADULTS,
ELDERLY: Initially,
give 20 mg q8h
(30 mg twice a day
[sustained-release
capsules]), then
titrate.
5. Mannitol Usual Dosage Elevates osmotic Frequent: Dry BASELINE
man-it-ol Test Dose (to pressure of mouth, thirst. ASSESSMENT
(Osmitrol) assess adequate glomerular filtrate, Occasional: Blurred Check B/P, pulse before
PHARMACOTHE renal function): inhibiting tubular vision, increased giving medication.
RAPEUTIC: ADULTS, reabsorption of urinary frequency/ Assess skin turgor,
Polyol ELDERLY: 12.5 g water and volume, headache, mucous membranes,
(sugar alcohol). (200 mg/kg) over 3– electrolytes, arm pain, mental status, muscle
CLINICAL: 5 min to produce resulting in backache, nausea, strength.
Osmotic urine flow of at least increased flow of vomiting, urticaria, Obtain baseline weight,
diuretic, 30–50 ml urine/hr. water into dizziness, chemistry studies.
antiglaucoma, CHILDREN: interstitial hypotension, Assess I&O.
antihemolytic. 200 mg/kg over 3–5 fluid/plasma. hypertension, INTERVENTION/EVALUA
min to produce Therapeutic Effect: tachycardia, fever, TION
urine flow of at least Produces diuresis; angina-like chest Monitor urinary output to
1 ml/kg for 1–3 hrs. reduces intraocular pain. ascertain therapeutic
Initial: ADULTS, pressure (IOP), Fluid, electrolyte response. Monitor serum
ELDERLY: 0.5–1 intracranial imbalance may electrolytes, BUN,
g/kg. pressure (ICP), occur due to rapid renal/hepatic function
CHILDREN: 0.25–1 cerebral edema. administration of tests.
g/kg. large doses or Assess vital signs, skin
Maintenance: inadequate urine turgor, mucous
ADULTS, output resulting in membranes. Weigh daily.
ELDERLY: 0.25– overexpansion of Signs of hyponatremia
0.5 g/kg q4–6h. extracellular fluid. include confusion,
CHILDREN: 0.25– Circulatory overload drowsiness, thirst, dry
0.5 g/kg q4–6h. may produce mouth, cold/clammy skin.
pulmonary edema, Signs of hypokalemia
CHF. Excessive include changes in muscle
diuresis may strength, tremors, muscle
produce cramps, altered mental
hypokalemia, status, cardiac
hyponatremia. Fluid arrhythmias. Signs of
loss in excess of hyperkalemia include
electrolyte excretion colic, diarrhea, muscle
may produce twitching followed by
hypernatremia, weakness,paralysis,
hyperkalemia. arrhythmias.
PATIENT/FAMILY
TEACHING
• Expect increased urinary
frequency/volume.
• May cause dry mouth.
IVF Amount Infusion rate Purpose Nursing responsibilities

1,000 mL KVO or 10 gtts/min Accessibility for Document baseline data,

1.PNSS administering drugs do not adminsiter in
contraindicated
conditions, monitor for
manifestations of fluid
volume deficit, monitor for
 warning signs on
excessive infusion, keep
the IV insertion site clean,
and monitor for signs of IV
line complications such as
extravasation, redness,
and infiltration.

Diagnostic Description Purpose Nursing Responsibilities

Procedure
 Explain the procedure to the
1. A recording of  Detect and patient. Inform the patient that
Echocardiogram electrical changes evaluate echocardiography is used to
that accompany the valvular evaluate the size, shape, and
cardiac cycle that abnormaliti motion of various cardiac structures.
can be detected at es Tell who will perform the test, where
the surface of the  Detect it will take place, and that it’s safe,
body; maybe atrial painless, and is noninvasive.
resting, stress, or tumors  No special preparation is
ambulatory.  Measure needed. Advise the patient that he
the size of doesn’t need to restrict food and
the heart fluids for the test.
chambers  Ensure to empty
 Evaluate the bladder. Instruct patient to void
chambers prior and to change into a gown.
and valves  Encourage the patient to
in cooperate. Advise the patient to
congenital remain still during the test because
heart movement may distort results. He
disorders may also be asked to breathe in or
2. 12 lead ECG The 12-lead ECG  Diagnose out or to briefly hold his breath
gives a tracing from hypertrophi during the exam.
12 different c and  Explain the need to darken the
“electrical positions” related examination field. The room may be
of the heart. Each cardiomyop darkened slightly to aid visualization
lead is meant to athies on the monitor screen, and that
pick up electrical  Evaluate other procedure (ECG and
activity from a cardiac phonocardiography) may be
different position on function or performed simultaneously to time
the heart muscle. wall motion events in the cardiac cycles.
after  Explain that a vasodilator (amyl
myocardial nitrate) may be given. The patient
infarctions may be asked to inhale a gas with a
 Detect slightly sweet odor while changes in
pericardial heart functions are recorded.
effusion
and mural
thrombi.
 this allows
an
experience
d
interpreter
to see the
heart from
many
different
angles.

 Assist in
4. Chest X-ray a painless, non- Before Chest X-ray:
the
invasive test uses  Remove all metallic objects. Items such
diagnosis
electromagnetic as jewelry, pins, buttons etc can hinder
of
waves to produce the visualization of the chest.
diaphragm
visual images of the
atic hernia,  No preparation is required. Fasting or
heart, lungs, bones, medication restriction is not needed
lung
and blood vessels unless directed by the health care
tumors,
of the chest. Air provider.
and
spaces normally
metastasis  Ensure the patient is not pregnant or
seen in the lungs suspected to be pregnant. X-rays are
appear dark on the  Detect
chest films. known or usually not recommended for pregnant
suspected women unless the benefit outweighs
pulmonary, the risk of damage to the mother and
cardiovasc fetus.
ular, and  Assess the patient’s ability to hold his
skeletal or her breath. Holding one’s breath
disorders after inhaling enables the lungs and
 Identify the heart to be seen more clearly in the x-
presence of ray.
chest  Provide appropriate clothing. Patients
trauma are instructed to remove clothing from
 Confirm the waist up and put on an X-ray gown
correct to wear during the procedure.
placement  Instruct patient to cooperate during the
and procedure. The patient is asked to
position of remain still because any movement will
the affect the clarity of the image.
endotrache After Chest X-ray:
al tube,  No special care. Note that no special
tracheosto care is required following the procedure
my tube,  Provide comfort. If the test is facilitated
chest at the bedside, reposition the patient
tubes, properly.
central
venous
catheters,
nasogastric
feeding
tube,
pacemaker
wires,
intraortic
balloon
pump,
Swan-Ganz
catheters,
and
automatic
implantable
cardioverte
r
defibrillator
 Evaluate
positive
purified
protein
derivative
(PPD) or
Mantoux
test for
pulmonary
tuberculosi
s.
 Monitor
progression
s,
resolutions,
or
maintenanc
e of
disease
 Evaluate
the
patient’s
response to
a
therapeutic
regimen
(antibiotic,
chemother
apy)
  To evaluate
4. MRI A noninvasive bony and Patient Preparation:
technique, skeletal soft-tissue  Make sure the scanner can
magnetic tumors. accommodate the patient’s weight and
resonance imaging  To identify abdominal girth.
(MRI) produces changes in  Explain to the patient that skeletal MRI
clear and sensitive bone assesses bone and soft tissue. Tell him
images of bone and marrow who will perform the test and where it
soft tissue. The compositio will take place.
scan provides n.  Explain that the test takes 30 to 90
superior contrast of  To identify minutes.
body tissues and spinal  Explain to the patient that although MRI
allows imaging of disorders. is painless and involves no exposure to
multiple planes, radiation from the scanner, a contrast
including direct medium may be used, depending on
sagittal and coronal the type of tissue being studied.
views in regions  If the patient is claustrophobic or if
that can’t be easily extensive time is required for scanning,
visualized with X- explain to him that a mild sedative may
rays or computed be administered to reduce anxiety.
tomography scans. Open scanners have been developed
MRI eliminates any for use on the patient with extreme
risks associated claustrophobia or morbid obesity, but
with exposure to X- tests using such machine take longer.
ray beams and  An anesthesiologist may need to be
causes no known present to monitor a heavily sedated
harm to cells. patient.
 Tell the patient that he must lie flat, and
describe the test procedure.
 Explain to the patient that he’ll hear the
scanner clicking, whirring, and
thumping as it moves inside its
housing.
 Reassure the patient that he’ll be able
to communicate with the technician at
all times.
 Instruct the patient to remove all
metallic objects, including jewelry,
hairpins, or watches.
 Stop I.V. infusion pumps, feeding tubes
with metal tips, pulmonary artery
catheters, and similar devices before
the test.
 Ask whether the patient has any
surgically implanted joints, pins, clips,
valves, pumps, or pacemakers
containing metal that could be attracted
to strong MRI magnet. If he does, he
won’t be able to have the test.
 Note and report all allergies.
 Make sure that the patient or a
responsible family member has signed
an informed consent form, if required.
MRI Procedure:
 At the scanner room door, check the
patient one last time for metal objects.
 The patient is placed on a narrow,
padded, nonmetallic table that moves
into the scanner tunnel. Fans
continuously circulate air in the tunnel,
and a call bell or intercom is used to
maintain verbal contact.
 Remind the patient to remain still
throughout the procedure.
 While the patient lies within the strong
magnetic field, the area to be studied in
stimulated with radio-frequency waves.
 If the test is prolonged with the patient
lying flat, monitor him for orthostatic
hypotension.
 Provide comfort measures and pain
medication as needed and ordered
 because of prolonged positioning in the
scanner.
 After the test, tell the patient that he
may resume his usual activity.
 Provide emotional support to the
patient with claustrophobia or anxiety
over his diagnosis.
 Nursing Interventions for MRI
 Provide patient with comfort measures
as needed.
 Tell the patient to resume his normal
diet and activities unless otherwise
indicated.
 Monitor vital signs.
 Monitor the patient for orthostatic
hypotension.
 MRI Precautions
 Be aware that MRI can’t be performed
on a patient with a pacemaker,
intracranial aneurysm clip, or other
ferrous metal implants. Ventilators, I.V.
infusion pumps, oxygen tanks, and
other metallic or computer based
equipment must be kept out of the MRI
area.
 If the patient is unstable, make sure an
I.V. line without metal components is in
place and that all equipment is
compatible with MRI imaging. If
necessary, monitor the patient’s
oxygen saturation, cardiac, rhythm, and
respiratory status during the test. An
anesthesiologist may be needed to
monitor a heavily sedated patient.
 Make sure that the technician
maintains verbal contact with the
conscious patient.

 CT scans
5. CT Scan a painless, non- can detect Before the procedure:
invasive diagnostic bone and  Informed Consent. Obtain an informed
imaging procedure joint consent properly signed.
that produces problems,  Look for allergies. Assess for any
cross-sectional like history of allergies to iodinated dye or
images of several complex shellfish if contrast media is to be used.
types of tissue not bone  Get health history. Ask the patient
clearly seen on a fractures about any recent illnesses or other
traditional X-ray. and medical conditions and current
tumors. medications being taken. The specific
 If you have type of CT scan determines the need
a condition for an oral or I.V. contrast medium
like cancer,  Check for NPO status. Instruct the
heart patient to not to eat or drink for a period
disease, amount of time especially if a contrast
emphysem material will be used.
a, or liver  Get dressed up. Instruct the patient to
masses, wear comfortable, loose-fitting clothing
CT scans during the exam.
can spot it  Provide information about the contrast
or help medium. Tell the patient that a mild
doctors see transient pain from the needle puncture
any and a flushed sensation from an I.V.
changes. contrast medium will be experienced.
 They show  Instruct the patient to remain still.
internal During the examination, tell the patient
injuries and to remain still and to immediately report
bleeding. symptoms of itching, difficulty breathing
 They can or swallowing, nausea, vomiting,
help locate dizziness, and headache.
a tumor,  Inform about the duration of the
blood clot, procedure. Inform the patient that the
excess procedure takes from five (5) minutes
 fluid, or to one (1) hour depending on the type
infection. of CT scan and his ability to relax and
 Doctors remain still.
use them to
guide After the procedure:
treatment  Diet as usual. Instruct the patient to
plans and resume the usual diet and activities
procedures unless otherwise ordered.
, such as  Encourage the patient to increase fluid
biopsies, intake (if a contrast is given). This is so
surgeries, to promote excretion of the dye.
and
radiation
therapy.
 Doctors
can
compare
CT scans
to find out if
certain
treatments
are
working.

A doctor will
6. Carotid is a painless recommend  There is little or no special preparation
Ultrasound imaging test that carotid ultrasound is required for this procedure. Leave
uses high- if you have jewelry at home and wear loose,
frequency sound transient ischemic comfortable clothing. A loose-fitting,
waves to create attacks (TIAs) or open necked shirt or blouse is ideal.
pictures of the certain types of
inside of your stroke and may  Explain to the patient the purpose of
carotid arteries.A recommend a the procedure to alleviate anxiety.
Doppler ultrasound carotid ultrasound
study – a technique if you have
that evaluates blood medical conditions
flow through a that increase the
blood vessel – is risk of stroke,
usually part of this including:
exam. It's most  High blood
frequently used to pressure
screen patients for  Diabetes
blockage or  High
narrowing of the cholesterol
carotid arteries, a  Family
condition called history of
stenosis which may stroke or
increase the risk of heart
stroke. It uses a disease
small probe called a  Recent
transducer and gel transient
placed directly on ischemic
the skin. High- attack (TIA)
frequency sound or stroke
waves travel from
 Abnormal
the probe through
sound in
the gel into the
carotid
body. The probe
arteries
collects the sounds
(bruit),
that bounce back. A
detected by
computer uses
your doctor
those sound waves
using a
to create an image.
stethoscop
Ultrasound exams
e
do not use radiation
 Coronary
(as used in x-rays).
artery
Because images
disease
are captured in real-
time, they can show
the structure and
movement of the
body's internal
 organs. They can
also show blood
flowing through
blood vessels.
Reference/s: Health Assessment in Nursing by Janet R. Weber, Brunner & Suddarth’s Medical Surgical
Nursing, Tortora’s Principle of Anatomy & Physiology, http://www.learningradiology.com/,
https://nursing.uworld.com/nclex-rn/, https://www.medscape.com/, Nursing Drug Handbook 2018 Wolters
Kluwer

FEEDBACK: I hope you were not intoxicated by these drugs. Remember that these are important
in saving your patient’s life and it should be monitored for its therapeutic and side effects.

ACTIVITY 6: Applying the nursing process, integrate all the significant findings obtained in the
analysis of the case and formulate a nursing care plan for your patient. Use the given table/format
presented.

DATA GOALS/ ACTION/ RATIONALE RESPONSE &

Expected outcomes NURSING EVALUATION
INTERVENTIO
NS
Subjective findings: STG: within 8 hour of Dxtc: >helps to After 8 hr/s of NI, the
"wala na siyang malay NI the patient will > Assessed patient was able to
identify the
at hindi na demonstrate stable VS as
demonstrate stable general health
medical need manifested by lower BP to
nagreresponde kahit vital signs as status 130/80 and SPO2 level of
of patients.
anong gawin ko. manifested/evidence 95%,
Patigil tigil ang STG: partially met
d by: improved BP > check
paghinga niya" as > Cardiac
and SPO2 level.
respirations and
verbalized by the wife. LTG: after 7 days of pump After 7 days of NI, the
Objective findings: absence of patient was able to
NI the patient will be malfunction
 BP: 140/90 work of demonstrate stable VS as
able to: maintain and/or manifested by lower BP to
 PR: 62 bpm breathing 130/80 and SPO2 level of
improved level of ischemic pain
 RR: 24 95%, conscious and
consciousness, may result in responsive to commands
 Temp: 36.7°C
respiratory and instructions.
 SPO2: 90% cognition, and
LTG: fully met
 Capillary refill motor/sensory distress.
of 5 seconds function as Nevertheless,
 IVF of 0.45% manifested by: verbal abrupt or
NSS 1L x KVO continuous
or non-vebal
@750cc dyspnea may
response from
stimulus. signify
Focus/ Nursing Dx:
thromboemboli
(PE/S)
c pulmonary
Ineffective cerebral
tissue perfusion r/t complications
interruption of blood
flow secondary to > Stable BP is
CVD, Hemorrhagic > monitored VS
needed to
left thalamic, left q 1hr
keep sufficient
cerebral peduncle and
tissue
Pons with intra
perfusion.
ventricular extension.
Medication
effects such as
altered
autonomic
control,
decompensate
d heart failure,
reduced fluid
 volume, and
vasodilation
are among
many factors
potentially
jeopardizing
optimal BP.

> checked NGT >to avoid lung

patency aspiration
during feeding
> monitored > Sufficient
I&O fluid intake
maintains
adequate
filling
pressures and
optimizes
cardiac output
needed for
tissue
perfusion.
Reduce renal
perfusion may
take place due
to vascular
occlusion.

Txc:
> changed >decrease
position to intracranial
semi-fowlers pressure
position
>Assisted in >body
performing movements
ROM and increases
changing body blood
position from circulation
side to side
>performed >clearing
pharyngeal airway from
suctioning q 4 secretions
hours to clear brought by
secretions productive
cough helps
oxygenation.
 >administered > medications
medications as facilitate
prescribed perfusion for
most causes of
impairment,
reduce blood
viscosity and
coagulation,
enhance
arterial
dilation,
improve
peripheral
blood flow,
reduce
systemic
vascular
resistance,
and optimize
cardiac output
and perfusion.

Edx:
> Provided > Knowledge
knowledge to of causative
the wife about factors
normal tissue provides a
perfusion and rationale for
possible causes treatments.
of impairment, Understanding
explained her expected
all the events and
procedures and sensations can
treatments, the help eliminate
importance of anxiety
lifestyle associated
modification with the
that could unknown.
improve tissue Early
perfusion, how assessment
to recognize the facilitates
signs and immediate
symptoms that treatment.
need to be
reported.

FEEDBACK: CONGRATULATIONS, you have just shown how prepared you are in meeting your
patient’s needs. If this continues, expect that a lot of your patient will be smiling and thanking
you for saving their lives.

COLLABORATION
Activity 7: As a future nurse you should be able to work with your co-nurses and other health care
professionals and form a team sharing knowledge and resources to solve or provide patient care.
⮚ After administering the nursing and medical interventions, you assessed that the edema of patient X
did not subside. As a nursing student what are you going to do next? (limit you answers in 3-5
sentences only.)
I will approach and talk to one of the staff nurses to report the issue. Explain that despite all the
dependent and independent interventions, the edema didn’t subside.

FEEDBACK: WELL DONE! You have contributed in making the health care team working as one
for the benefit of the patient.

ETHICO-MORAL-LEGAL CONCERNS
Activity 8: These principles concern the ethics of caring rather than 'curing' by exploring the
everyday interaction between you as a nurse and the person in your care.
⮚ In this situation what are the possible ethico-moral and legal concerns of your patient. Justify you
answer in 3-5 sentences only.
Providing nursing care to unconscious patient call attention to may ethical dilemmas. Some of these
patients either die or recover within a few days or so. The patient is unaware of his environment
worse comes to worst, on coma. Every intervention must be done with consent of the significant
others because the patient participate in the decision. As a nurse, it is very important to communicate
well with the team in delivering or providing interventions.

FEEDBACK: WELL DONE! You are almost done, it’s not time to give up. Take a deep breath,
cool down, and proceed. Now summarize what you have done by formulating the concept
map/table.
ACTIVITY 9:
Incorporating all the data that had been presented to you and your readings, create in a diagram
form the pathophysiology of the patient’s disease/condition. Incorporate the risk factors present
in your patient based on his/her history, the signs and symptoms presented by your patient as
shown on his/her PE and ROS, the lab results provided by the various diagnostic exams. Group
all cues together showing how you were able to arrive to a certain nursing diagnosis/es.
Lastly, include the various medications and or procedures. Do not forget to include the arrows to
show connections and/or relationships among the various concepts.

Study the given sample below for you to understand.

BE CREATIVE BUT KEEP IT SIMPLE GOOD LUCK!

HEART BRAIN ENDOCRINE SYS

↓Atrial natriuretic ↑SNS ↑Aldosterone/corticos
peptide ↓PSNS teroids
↓Brain natriuretic ↑Vasopressin ↑Leptin
peptide ↓Adiponectin
↑Cardiac Output ↑Insulin
↑Heart Rate ↑Thyroid hormones
↑Growth
↑estrogens/androgens
RENAL FACTORS
IMMUNE SYS ↑Renin-angiotensin-
↑Neoantigens aldosterone system
↑T- ↑Renal-sodium and water
 VASCULATURE
↑Endothelin
↓Nitric oxide
↓Prostaglandins
↑Calcifications
↑stiffness

HYPERTENSION

↑Blood Pressure in the cerebrovascular

Rapturing of the cerebrovascular

Bleeding or hemorrhage in left thalamic, left cerebral

Penduncle including Pons

Inflammation, edema, and hemorrhage

Increased ICP

Diffused damage to the cerebral tissues

Blocks the signal to the RAS (Reticular Activating System)

Unconsciousness

INEFFECTIVE CEREBRAL TISSUE PERFUSION

Feedback: Congratulations, you are helping yourself achieve your dream of becoming a nurse.
Keep up the good work.

COMMUNICATION
Activity 10: Your shift is about to end, using ISBAR (a patient safety communication structure
that aids simplified, effective, structured and anticipated communication between healthcare
personnel). Fill in your end of shift report to help guide the incoming student nurse.
Identify yourself: your name: Eduardo Lofstedt Jr. role: student nurse ward/area: Medical Ward
4
Situation: What is your patient’s name, age & gender, current situation/status (stable but in danger
of deterioration, unstable), concern or your observations, what needs to monitor/observe (ex;
abnormal VS, labs, active clinical signs/symptoms)
Patient X at bed 9 , 56 y/o, with an IVF of 0.45% NSS 1L x KVO 700cc left, with an O2 at 2L/min
via NC, on NGT with special diet, no bathroom privileges,
Background: Give the relevant details such as presenting problems and clinical history that will
help the incoming staff interpret the situation easily; may also include meds / procedures already
administered.
Admitting diagnosis of the patient is CVD, probably pontline area, HPN Stage II with a chief
complaints of unconsciousness. Two days prior to admission, early in the morning, September 03, 2020,
the patient’s wife noticed that her husband is unresponsive, irregular respirations with pauses at the end
of inspiration and expiration, unconscious and no reactions at all to any types of stimuli so the wife
immediately brought her husband into the nearest hospital by the use of the police car in their barangay
since they don’t have the means to transport and hence admitted. Upon arrival, a plain CT scan was
conducted and done at the hospital, Veterans’ Regional Hospital and then the wife decided to transfer
the patient here at Baguio General Hospital and Medical Center for more consistent care and proper
treatment. Official CT scan reading shows an acute haemorrhage at the center thalamus extending to the
left cerebral peduncle and pons. The patient had a traumatic car accident way back year 2005. He had
undergone a laser operation of kidney stone at St. Lukes Medical Center, Quezon City in the year 2007.
He was first diagnosed with cerebrovascular disease at year 2016. Upon according to his wife, patient
encountered fever, headache, cough and colds these past months. No known allergies. According to his
wife, the patient’s parents died due to stroke and cardiac problems. His older brother died due to cardiac
arrest. His family also has a history of diabetes and hypertension.
Assessment: What is your assessment? (Base it on your observation on your patient during your
shift what is his/her current condition, risks & needs).
Patient vitals signs was monitored every hour, BP went down to 130/80 from 140-90 after administering
medications Nicardipine, Captopril, Lovastatin, and Atorvastatin, SPO2 went up to 95% from 90% after
performing Assisted ROM and shifting body position from side to side every after 2 hours, he is still
unconscious and unresponsive while performing bedside care at the end of the shift but vital signs
improved.
Recommendation: What do you recommend being done to correct the situation? Be clear about
what you are requesting. (e.g transfer/review/treatment? When should it happen?

Please continue monitoring VS q 1 hr, administer medications as prescribed.

Feedback: CONGRATULATIONS, you have carried out your task. I will be getting back to you
after I have read your output.