I.

Biographic Data

Name : Olimpio Tubise

Age : 50 years old
Gender : Male
Religious Affiliation : Roman Catholic
Marital Status : Married
Occupation : Pedicab driver
Chief Complaint : Paralysis of the left extremity
Initial Diagnosis : Cerebro Vascular Disease; Left Ventricular
Hypertrophy
Date of Admission : June 23, 2006
Time of Admission : 10:44 PM
Hospital of Admission : Ospital ng Maynila - ER

II. Nursing History

A. Past Health History

The family reported that Mr. Tubise had no history of past illnesses except for
fever, cough and colds.

B. History of Present Illness

Few hours PTA, patient was noticed to developed loss of consciousness lasting for
more than 10 minutes. Patient was then rushed at Ospital ng Maynila – Emergency
Room, where the family as well as Mr. Olimpio himself noticed that he cannot
move the left side of his body and had dizziness. Also during interaction, slurring of
speech is manifested by the patient. Upon arriving at OM-ER, patient was hooked
to an IV Fluid of Plain NSS to run for 8 hours at a rate of 31 – 32 gtts/min. The
patient was for CT scan and for complete blood test.

C. Family Health History

The family of Mr. Tubise is negative in Diabetes Mellitus, Hypertension, and cardiac
Diseases.

III. Patterns of Functioning

A. Psychological Health

1. Coping Patterns

The client’s family verbalized that whenever he had problems or burdens

he just kept it on himself. He sometimes diverts his attention through
drinking alcohols, so even for a while he can forget the matter.

2. Interaction Pattern

According to the client’s family Mr. Olimpio relates well with other people
around him. For him, drinking alcohol is one way of showing your
“pakikisama” with other people. He never experiences any problems
 regarding his relationship with other people because he knows how to
adopt or adjust into a certain situation.

Analysis:

Middle aged adults are in the stage of GENERATIVITY VS. STAGNATION. In other words, the
concern of providing for the welfare of human kind is equal to the concern of providing for self.
They seems more altruistic, and concepts of service to others and love and compassion gain
prominence. Generative middle aged person are able to feel a sense of comfort in their
lifestyle and receive gratification from charitable endeavors. Middle aged learning continues
and can be enhanced by increased motivation at this time. They are able to carry out all the
strategies described in Piaget’s phase of formal operations. Some may use post formal
strategies to assist them in understanding the contradictions that exists in both personal and
physical aspects of reality. The experiences of the professional, social and personal life of
middle-aged person will be reflected in their cognitive performance. They can reflect on the
past and current experience and can imagine, anticipate, plan and hope.
(Fundamentals of Nursing by Kozier, 7th edition, pp.398-400)
Interpretation:

The client was able to achieve his generativity stage and one indications of this is his positive
perception on things that involves other people around him, however, the only problem that I
was able to notice was his improper way of managing his emotions (i.e. sadness) because this
might cause a negative effect on his health.

B. Socio-Cultural Patterns

1. Cultural Patterns

The client’s family verbalized that he is used to attending fiestas and other
occasions as part of “pakikisama” and respect with the tradition and
culture of the Filipinos. They also mentioned that they also celebrate
Christmas and New Year.

2. Significant Relationship

The client’s family verbalized that the most important relationship that he
has is with his family since the death of his wife. Second is with his
companions.

3. Environment

The client verbalized that he doesn’t have any problem with regards to his
environment because he can easily adjust into it and with the person’s
around him.

C. Spiritual Pattern

1. Religious Beliefs and Practices

The client’s family verbalized that he belongs to Roman Catholic but he

seldom go to church during Sundays and he doesn’t involve himself into any
church organizations or activities. However, they said that he always prays
before and after eating, before sleeping and after waking up in the
morning.
Analysis:

As individuals approach middle age, physical strength and attractiveness decline. It then
becomes necessary to be given satisfaction and ego strength through mental and intellectual
abilities. They must rely more on their wisdom and accumulated experiences than in their
physical powers. Middle aged adults are in the PARADOXICAL-CONSOLIDATIVE stage. At this
stage, the individual can view truth from a no. of viewpoints. People tend to be less dogmatic
about religious belief and religion often offers more comfort to the middle aged adults than it
did previously. People in this age group often rely on spiritual beliefs to help them deal with
illness, death and tragedy.
(Fundamentals of Nursing by Kozier, 7th edition, p. 400)

Interpretation:

The client believes mostly in the existence of God because in him he entrust his safety and the
security of his family.

IV. Activities of Daily Living

ADL Before During Interpretation

Hospitalization Hospitalization
1. Nutrition Fond of eating fatty Soft diet with strict This is due to the
foods Aspiration presence of left
Precautions hemiparesis in the
client.
2. Elimination Stool: at least once Urine: none
per day Stool: none
3. Exercise Walking, Biking None
4. Hygiene 1x taking a bath none
5. Substance Abuse Drinks alcohol None Alcohol in take is
particularly gin 2 -4 prohibited to the
large bottles/day client to prevent
further damage and
complications.
6. Sleep and Rest 6-7 hours none
7. Sexual Activity None None

V. Physical Assessment
Body Part/ Technique Normal Findings Actual Findings Analysis
A General Appearance ----------------------- ------------------------
1. Apparent Age 50 years old
2. Sex ------------------------ Male --------------------------
3. Hygiene Clean, neat, no body Presence of body odor Unilateral neglect (total
odor or minor odor and bad breath inattention to one side of
relative to work or the body) occurs
exercise; no bad following some
breath odor. cerebrovascular
(Kozier. Fundamentals accidents. (Jarvis.
of Nursing. 5th Physical Examination and
ed,p.473) Health Assessment. 4th
Ed. P108)
4. Gait The person moves with Hemiplegic at left side Hemiparesis (weakness)
a sense of freedom. or Hemiplegia of one side
 The Gait is smooth, of the body may occur
rhythmic, and after a stroke. These
effortless; the Deficits are usually
opposing arm is caused by a stroke in the
coordinated; the turns anterior or middle
are smooth. (Jarvis. cerebral artery, leading
Physical Examination to the infarction in the
and Health motor strip of the frontal
Assessment. 4th Ed. cortex. (Black, Joyce M.
P677) and Jane Hokanson
Hawks. Medical-Surgical
Nursing: Clinical
Management for Positive
Outcomes. 7th ed. Vol 2.
P.2111)
7. Skin Color and Generally uniform Uniform except in the Normal
Condition except in areas not palms, and lips – dark
exposed to the sun; skin complexion
areas of lighter
pigmentation (palms,
lips, nail beds), in dark
skinned people.
(Kozier. Fundamentals
of Nursing, 7th ed.
p.538)
B. Vital Signs Oral: 37.06°C Axillary: 36.40°C Normal
 Body (98.6°F)
Temperature Axillary: 36.4 C
(97.6°F)
Rectal: 37.6°C (99.6°F)
Forehead: 34.4°C
(94.0°F)
Tympanic: 37.7°C
(99.9°F)
(Kozier. Fundamentals
of Nursing,5th ed,
p.427)
 Pulse rate Average: 80 beats per 51 beats per minute Slow bounding pulse or
minute Bradycardia may be
Female: 75 beats per manifested to the
minute patient with stroke, due
Male: 70 beats per to the acute change in
minute cerebral perfusion.
Range: 60-100 beats (Black, Joyce M. and
per minute Jane Hokanson Hawks.
(Kozier. Fundamentals Medical-Surgical Nursing:
of Nursing, 5th ed. Clinical Management for
p.38) Positive Outcomes. 7th
ed. Vol 2. P.2124)
 Respiratory Rate Average: 16 breaths 21 breaths per minute Altered pattern of
per minute Breathing due to the
Range: 12-20 breaths acute change in cerebral
per minute perfusion.
(Kozier. Fundamentals (Black, Joyce M. and
of Nursing,5th ed p.438) Jane Hokanson Hawks.
 Medical-Surgical Nursing:
Clinical Management for
Positive Outcomes. 7th
ed. Vol 2. P.2124)
 Blood Pressure The average blood 130/80 mmHg Hypertension frequently
pressure of a healthy accompanies acute
adult is 120/80 mm. ischemic stroke due to
Hg. the decreased cerebral
Systolic BP range: blood flow.
95-140 mm. Hg. (Black, Joyce M. and
Diastolic BP range: Jane Hokanson Hawks.
60-90 mm. Hg. Medical-Surgical Nursing:
(Kozier. Fundamentals Clinical Management for
of Nursing,5th ed p.448 Positive Outcomes. 7th
and p.52) ed. Vol 2. P.2121)
 Cardiac rate Pulse Ranges 51 beats per minute Bradycardia may be
(PMI) 60 – 100 bmp – Adult manifested to the
(Kozier. Fundamentals patient with stroke, due
of Nursing, 7th ed. to the acute change in
p485) cerebral perfusion.
(Black, Joyce M. and
Jane Hokanson Hawks.
Medical-Surgical Nursing:
Clinical Management for
Positive Outcomes. 7th
ed. Vol 2. P.2124)
Head Rounded Normocephalic and Normal
A. Skull (normocephalic and symmetrical with the
symmetrical, with bony prominences
frontal, parietal, and
occipital prominences);
smooth skull contour.
(Kozier. Fundamentals
of Nursing,5th ed. p.481
B. Scalp White, clean, free Lighter than the shade Normal
from masses, lumps, of his body and free
scars, lice, nits and from scars, lice, lumps,
dandruff and lesions. masses, lesion, and
(Lippincott’s Review dandruff.
Series by Muscari,
p.16)
C. Hair Evenly distributed hair, Evenly distributed, Normal
silky, and thick. silky
(Kozier. Fundamentals
of Nursing,5th edp.478)
Body Parts Symmetric or slightly Slightly asymmetrical Weakness of the lower
A. Face asymmetric; half of the face. Causes:
symmetrical facial Stroke, corticobulbar
movements. tract. (Black, Joyce M.
(Kozier. Fundamentals and Jane Hokanson
of Nursing,5th ed. Hawks. Medical-Surgical
p.481) Nursing: Clinical
Management for Positive
Outcomes. 7th ed. Vol 2.
P.2018)
B. Eyes Parallel and evenly No protrusions. Normal
placed, symmetrical Symmetrical
and non-protruding,
with scant amount of
secretions.
(Kozier. Fundamentals
of Nursing,5th ed.
p.483)
C. Eyebrows Hair evenly Evenly distributed Normal
distributed; skin
intact, symmetrically
aligned, and has equal
movement.
(Kozier. Fundamentals
of Nursing,5th ed.
p.483)
D. Eyelashes Equally distributed; Equally distributed, Normal
curled slightly curled slightly outward
outward.
(Kozier. Fundamentals
of Nursing. 5th ed.
p.483)
E. Eyelids Lids close Incomplete eyelid Important cause that you
symmetrically. When closure may see on general
lids open, no visible medical wards is
sclera above cornea, neurological disease
and the upper and (most commonly a
lower borders of cerebrovascular
cornea were slightly accident) that affects
covered. No edema or the seventh cranial nerve
tenderness over which supplies the
lacrimal glands. obicularis muscle.
(Kozier. Fundamentals (Sophia Pathai and
of Nursing,5th edp.483) Andrew McNaught.
Opthalmology: Eyelid
Problems.
http://www.studentbmj.
com/issues/03/03/educa
tion/54.php)
F. Conjuctivae Shiny, smooth, and Pinkish in color Normal
pinkish or reddish
(Kozier. Fundamentals
of Nursing,5th ed.p.484)
G. Sclera Sclera appears white; Appears white Normal
capillaries sometimes
evident.
(Kozier. Fundamentals
of Nursing,5th edp.484)
H. Cornea Transparent, shiny and Transparent Normal
smooth
(Kozier. Fundamentals
of Nursing,5th ed.
p.485)
I. Pupils Black in color; equal in Pupils equally round, Normal
size; normally 3-7 mm reactive to light, and
 in diameter; round, accommodative.
smooth border.
Illuminated pupils
constricts; non-
illuminated pupils,
dilates; pupils
constricts when looking
at a near object, and
dilate when looking at
far objects; pupils
converge when near
object is move towards
nose.
(Kozier. Fundamentals
of Nursing,5th ed.p.486)
J. Iris Proportional to the size Symmetrical and Normal
of the eyes, round, proportional to the
black/brown and eyes
symmetrical.
(Mosbey. Physical
Assessment, p.1118)
K. Ears Color same as facial Color same as facial Normal
skin; symmetric skin, symmetrical, and
position line drawn fro recoils quickly
lateral angle of eye to
point where top part of
auricle joins head is
horizontal; auricles
must be mobile, firm
and not tender; recoils
after it is folded.
(Kozier. Fundamentals
of Nursing,5th ed.
p.492)
L. Nose Symmetrical and Symmetrical, no Normal
straight; no discharge; discharges
air moves freely as the
client breaths through
his nares.
(Kozier. Fundamentals
of Nursing. 5th
ed.p.497)
M. Mouth Uniform pink color, Pinkish in color and Normal
 Lips soft moist, smooth moist. Symmetrical in
texture, symmetry in contour.
contour.
(Kozier. Fundamentals
of Nursing.5th edp.499)
  Tongue Moves freely; no No tenderness and Normal
tenderness moves freely
(Kozier. Fundamentals
of Nursing,5th ed.p.501)

N. Neck Muscles equal in size; Uncoordinated Lack of coordination

head-centered; movement occurs with cerebellar
coordinated smooth disease.
movement with no (Black, Joyce M. and
discomfort; head Jane Hokanson Hawks.
reflexes 45 degrees. Medical-Surgical Nursing:
Central placement in Clinical Management for
midline of neck spaces Positive Outcomes. 7th
is equal on both sides. ed. Vol 2. P.681)
Glands ascend during
swallowing but are not
visible.
(Kozier. Fundamentals
of Nursing,5th ed.
p.506)
O. Upper Equal in size on both Unequal movement on Hemiparesis (weakness)
Extremities sides of the body; no left side; Grade 4 ROM or Hemiplegia of one side
contractions; normally – right side; Grade 1 of the body may occur
firm; no deformities; ROM – left side after a stroke. These
no tenderness or Deficits are usually
swelling. caused by a stroke in the
Grade 5: 100% of anterior or middle
normal strength; cerebral artery, leading
normal full movement to the infarction in the
against gravity and motor strip of the frontal
against minimal cortex. (Black, Joyce M.
resistance. and Jane Hokanson
(Kozier. Fundamentals Hawks. Medical-Surgical
of Nursing,7th ed Nursing: Clinical
pp.600- 601) Management for Positive
P. Lower Equal in size on both Unequal in size on both Outcomes. 7th ed. Vol 2.
Extremities sides of the body; no sides; no deformities; P.2111)
contractions; normally no tenderness, or
firm; no deformities; swelling. Grade 5 ROM
no tenderness or
swelling.
Grade 5: 100% of
normal strength;
normal full movement
against gravity and
against minimal
resistance.
(Kozier. Fundamentals
of Nursing,7th ed
pp.600- 601)
 Mobility Flexion of hips- 90 Unable to perform the Hemiparesis (weakness)
degrees knee range of movement or Hemiplegia of one side
 extended, 120 degrees exercises without any of the body may occur
knee flexed difficulty after a stroke. These
Extension of hips-90- Deficits are usually
120 degrees.Flexion caused by a stroke in the
and extension of anterior or middle
knees-120- 130 cerebral artery, leading
degrees. to the infarction in the
Flexion and extension motor strip of the frontal
of foot and toes- 35-60 cortex. (Black, Joyce M.
degrees. and Jane Hokanson
(Kozier.Fundamentals Hawks. Medical-Surgical
of Nursing,7th ed. Nursing: Clinical
pp.1063-1064) Management for Positive
Outcomes. 7th ed. Vol 2.
P.2111)
Q. Neurologic A fully conscious client Able to respond to Normal
Assessment responds to questions questions
 Level of spontaneously. (Potter instantaneously.
Consciousne and Perry.
ss Fundamentals of
Nursing. 6th ed. P.762)

 Sensory A client has sensory Unable to feel Hemisensory loss is

Function responses to all stimuli sensations bilaterally. attributed to stroke.
that are tested. (Black, Joyce M. and
Sensations are felt Jane Hokanson Hawks.
equally on both sides Medical-Surgical Nursing:
of the face, trunk, and Clinical Management for
extremities. (Potter Positive Outcomes. 7th
and Perry. ed. Vol 2. P.2119)
Fundamentals of
Nursing. 6th ed. P. 764)
 Coordination The client alternately Unable to demonstrate Lack of coordination
touches the nose coordination in the occurs with cerebellar
smoothly. Perform upper extremities. disease.
rapid, rhythmical, (Black, Joyce M. and
alternating, Jane Hokanson Hawks.
movements, Medical-Surgical Nursing:
demonstrates Clinical Management for
coordination in the Positive Outcomes. 7th
upper extremities. ed. Vol 2. P.681)
(Potter and Perry.
Fundamentals of
Nursing. 6th ed. P765)
Cranial Nerve Function A person can identify Able to identify odor Normal
I - Olfactory an odor on each side of on both sides of the
the nose. Smell is nose.
normally decreased
bilaterally with aging.
Any asymmetry in the
sense of smell is
important. (Jarvis.
Physical Examination
and Health
 Assessment. 4th ed.
P673)
III - Occulomotor A normal response is Able to trace object Occurs with the disease
IV – Trochlear parallel tracking of the only to the right side. of the vestibular system,
VI - Abducens object with both eyes. cerebellum, or brain
(Jarvis. Physical stem. (Jarvis. Physical
Examination and Examination and Health
Health Assessment. 4th Assessment. 4th ed. P673)
ed. P310)

V - Trigeminal Muscles should feel Difficulty in moving the Decreased strength on

equally strong on both jaws. unequal sensation one side, asymmetry in
sides You cannot jaw movement, and
separate the jaws by unequal sensation occurs
pushing down the chin. due to cerebrovascular
Sensation should be accident. (Jarvis.
bilateral (Jarvis. Physical Examination and
Physical Examination Health Assessment. 4th
and Health ed. P673-674)
Assessment. 4th ed.
P.673)
VII - Facial Mobility and facial Face movements are Weakness of the lower
symmetry as the asymmetrical half of the face. Causes:
person responds to Stroke, corticobulbar
these requests: smile, tract. (Black, Joyce M.
frown, close eyes and Jane Hokanson
tightly, lift eyebrows, Hawks. Medical-Surgical
show teeth, and puff Nursing: Clinical
cheeks. Then press the Management for Positive
person’s puffed cheeks Outcomes. 7th ed. Vol 2.
in, and note that the P.2018)
air should escape
equally from both
sides. (Jarvis. Physical
Examination and
Health Assessment. 4th
Ed. P675)
VIII – Auditory or Ability to hear normal Able to hear and Normal
Vestibulocochlear conversation, by the repeat whispered word
whispered voice test,
and by Weber and
Rinne tuning fork tests.
(Jarvis. Physical
Examination and
Health Assessment. 4th
Ed. P675)
IX - Glossopharyngeal Cranial nerve IX – Unable to say “Ah” Stroke is associated with
Muscles of the tongue, clearly. the impairment of
palate, pharynx or lips muscles of the tongue,
should move medially palate, pharynx or lips.
(Jarvis. Physical (Black, Joyce M. and
Examination and Jane Hokanson Hawks.
Health Assessment. 4th Medical-Surgical Nursing:
Ed. P675) Clinical Management for
Positive Outcomes. 7th
 ed. Vol 2. P.2018)
X - Vagus Touch the posterior Positive gag reflex Normal
pharyngeal wall with a
tongue blade, and note
the gag reflex. The
voice sounds must be
smooth and not
strained. (Jarvis.
Physical Examination
and Health
Assessment. 4th Ed.
P675)
XI - Accessory The person should be Unable to counter Hemiparesis (weakness)
able to counter the resistance on the left or Hemiplegia of one side
slight resistance placed side. Muscles are not of the body may occur
on the equally strong. after a stroke. These
sternocleuidomastoid Deficits are usually
and trapezius muscle. caused by a stroke in the
These movements anterior or middle
should feel equally cerebral artery, leading
strong on both sides. to the infarction in the
(Jarvis. Physical motor strip of the frontal
Examination and cortex. (Black, Joyce M.
Health Assessment. 4th and Jane Hokanson
Ed. P676) Hawks. Medical-Surgical
Nursing: Clinical
Management for Positive
Outcomes. 7th ed. Vol 2.
P.2111)
XII - Hypoglossal No wasting or tremors Able to move tongue Normal
should be present. without difficulty.
Jarvis. Physical
Examination and
Health Assessment. 4th
Ed. P676)

Glasgow Coma Scale Spontaneously 4 E=4 Total = 14/15

Best Eye Response (E) On command 3
To pain 2
No response 1

Best Verbal Response Alert and oriented 5 V=5 Denotes a slight deficit
(V) Confused 4
Inappropriate 3
Incomprehensible 2
No response 1
 Best Motor Response (M) Follows direction 6 M=5
Localizes pain 5
Withdraws from pain 4
Abnormal flexion 3
Abnormal extension 2
No response 1

VI. Laboratory and Diagnostic Exams Results

23 June Norm Actu Interpretation

2006 al al
Value Value
s* s
Increased number represents body fighting an infection or
4.8-
tissue damage
WBC 10.8 x 14.6
109 /L
http://www.ferret-universe.com/health/cbc.asp
RBC 4.0- 5.6 Normal
6.20 x
1012/L
HgB 14- 18.1 Mirrors RBC results
18g/d http://www.labtestsonline.org/understanding/analytes/cbc
L /test.html

Hct 42- 51.8 Normal

52%
MCV 81-99 93.0 Normal
fl
MCH Increased value is sign of hemolysis
(Mean
27-31 32.4
Corpuscular http://www.ferret-universe.com/health/cbc.asp
Hemoglobin)
MCHC
(Mean
Corpuscular
32-36 34.9 Normal
Hemoglobin
Concentrati
on)
Increased number represents clotting/thickening of the
150-
blood.
Platelet 400 x 461
109/L
http://www.ferret-universe.com/health/cbc.asp
Neutrophils 55- 77.4 High levels may indicate an active infection.
75%
http://www.saanendoah.com/bloodvalues.html
Decreased numbers are seen at beginning stages of infection
Lymphocyte 20- as well as with use of steroids like Prednisone.
11.7
s 30%
http://www.ferret-universe.com/health/cbc.asp
Monocytes 0-7% 6.9 Normal
Eosinophils 0-3% 3.1 Increased number can indicate current infection or allergy.
 http://www.ferret-universe.com/health/cbc.asp
Basophils 0-1% 0.9 Normal
*Based on the normal values of Ospital ng Maynila

VII. PATHOPHYSIOLOGY OF CEREBROVASCULAR ACCIDENT

Ischemia

Energy failure

Acidosis Ion imbalance

Glutamate Depolarization

Intracellular calcium
increased

Cell membrane and proteins break

down
Formation of free radicals
Protein production decreased

Cell injury and

DEATH
In an ischemic brain attack, there is disruption of the cerebral blood flow due to obstruction of
a blood vessel. This disruption in blood flow initiates a complex series of cellular metabolic
events referred to as the ischemic cascade.

The ischemic cascade begins when cerebral blood flow falls to less than 25 ml/100 g/min. At
this point, neurons can no longer maintain aerobic respiration. The mitochondria must then
switch to anaerobic respiration, which generates large amounts of lactic acid, causing a change
in the pH level. This switch to the less efficient anaerobic respiration also renders the neuron
incapable of producing sufficient qualities of adenosine triphosphate (ATP) to fuel the
depolarization process. Thus, the membrane pumps that maintain electrolyte balances begin
to fail and the cells cease to function.

Early in the cascade, an area of low cerebral blood flow, referred to as the penumbra region,
exists around the area of infarction. The penumbra region is ischemic brain tissue that can be
salvaged with timely intervention. The ischemic cascade threatens cells in the penumbra
because membrane depolarization of the cell wall leads to an increase in intracellular calcium
and the release of glutamate. The penumbra area can be revitalized by administration of
tissue plasminogen activator (t-PA), and the influx of calcium and the release of glutamate, if
continued, activate a number of damaging pathways that result in the destruction of the cell
membrane, the release of more calcium and glutamate, vasoconstriction, and the generation
of free radicals. These processes enlarge the area of infarction into the penumbra, extending
the stroke.

Each step in the ischemic cascade represents an opportunity for intervention to limit the
extent of secondary brain damage caused by stroke. Medications that protect the brain from
secondary injury are called neroprotectants. A number of clinical trials are focusing on
calcium channel antagonists that block the calcium influx, glutamate antagonists, antioxidants,
and other neuroprotectant strategies that will help prevent secondary complications.
VIII. Drug Study

Generic Name: CITICHOLINE

Classifications
Classification of citicholine is MEMBRANE PERMEABILITY ENHANCER
Actions
CDP-choline has putative activity as a cognition enhancer and in cell-membrane repair.

Indications
CDP-choline may be useful in the treatment of stroke and barin injury. There is some
preliminary evidence that CDP-choline may be helpful in some with tardive dyskinesia,
Parkinson’s disease, Alzheimer’s disease and other conditions characterized by impaired
cognitive function, including memory loss. An indication may emerge for it to help improve
visual acuity in those with amblyopia.

Side Effects
Adverse reactions reported include epigastric distress, nausea, rash, headache and
dizziness.

Nursing Responsibilities
The nurse should instruct the patient to report any allergies or untoward symptoms to
his physician immediately. Also tell the patient to follow all the instructions for taking
medication that the physician gave.

Generic Name: CAPTOPRIL

Classifications:
Classifications of this drug are CARDIOVASCULAR AGENT; ANGIOTENSIN-CONVERTING
ENZYME (ACE) INHIBITOR; ANTIHYPERTENSIVE AGENT

Actions
Lowers blood pressure by specific inhibition of the angiotensin-converting enzyme
(ACE). This interrupts conversion sequences initiated by renin that lead to formation of
angiotensin II, a potent endogenous vasoconstrictor. ACE inhibition alters hemodynamics
without compensatory reflex tachycardia or changes in cardiac output (except in patient with
CHF). Peripheral vascular resistance is lowered by vasodilation. Inhibition of ACE also leads to
decreased circulating aldosterone. Reduced circulating aldosterone is associated with a
potassium-sparing effect. In heart failure, captopril administration is followed by a fall in CVP
and pulmonary wedge pressure; hypotensive action appears to be unrelated to plasma renin
levels.
Indication
Captopril is used for patients with hypertension; in conjunction with digitalis and
diuretics in CHF, diabetic nephropathy

Side Effects
Side effects include hypersensitivity reactions, serum sickness-like reaction, athralgia,
skin eruptions and positive antinuclear antibody (ANA) titers. On cardiovascular system the side
effects are slight increase in heart rate, first dose hypotension, dizziness and fainting. On
gastrointestinal system there will be an altered taste sensation (loss of taste perception,
persistent salt or metallic taste) and weight loss. On hematologic system the side effects are
hyperkalemia, neutropenia, and agranulocytosis (rare). Cough on respiratory system.
Maculopapular rash, urticaria, pruritus, angioedema, photosensitivity on the skin and
Azotemia, impaired renal function, nephrotic syndrome, and membranous glomerulonephritis
on urogenital system.

Nursing Responsibilities
The nurse should monitor BP closely following the first dose because a sudden
exaggerated hypotensive response may occur within 1–3 h of first dose, especially in those with
high BP or on a diuretic and restricted salt intake. Monitor therapeutic effectiveness. At least 2
wk of therapy may be required before full therapeutic effects are achieved. Advise the patient
to have bed rest and BP monitoring for the first 3 h after the initial dose. Establish baseline
urinary protein levels before initiation of therapy and check at monthly intervals for the first 8
mo of treatment and then periodically thereafter. Perform WBC and differential counts before
therapy is begun and at approximately 2-wk intervals for the first 3 mo of therapy and then
periodically thereafter.
On teaching the patient, tell the patient or family of the patient to report to physician
without delay the onset of unexplained fever, unusual fatigue, sore mouth or throat, easy
bruising or bleeding (pathognomonic of agranulocytosis), to consult physician promptly if
vomiting or diarrhea occur. Also report to the physician if there is darkening or crumbling of
nailbeds (reversible with dosage reduction).
Inform them that mild skin eruptions are most likely to appear during the first 4 wk of
therapy and may be accompanied by fever and eosinophilia. Taste impairment occurs in 5–10%
of patients and generally reverses in 2–3 mo even with continued therapy. Use OTC medications
only with approval of the physician. Inform surgeon or dentist that captopril is being taken.
Alert diabetic patient that captopril may produce hypoglycemia. Monitor blood glucose and
HbA1c closely during first few weeks of therapy. And lastly tell the patient not to breastfeed
while taking this drug.

IX. List of Identified and Prioritized Nursing Problems

Date Identified Nursing Diagnosis Justification

June 23, 2006 Ineffective cerebral tissue
perfusion related to ischemia
June 23, 2006 Impaired physical mobility
related to hemiparesis
June 23, 2006 Impaired verbal
communication related to
impaired cerebral circulation
In assessing a patient with
deficits, it is necessary to
check for his ABC’s(airway,
breathing, circulation), in
this case, in a CVD patient,
circulation is of utmost
importance.
Our next priority is the
patient’s movement
secondary to the need of
improving circulation.
We chose communication as
the third priority for we saw
it necessary that the patient
 as manifested by dysarthria
and impaired articulation
June 23, 2006 Self-care deficit related to
neuromuscular impairment
June 23, 2006 Risk for injury related to
altered mobility
June 23, 2006 Disturbed tactile sensory
perception related to
neuromuscular impairment
June 24, 2006 Compromised family coping
related to temporary role
changes
X. Essential Nursing Care Management
During the interventions, the client is expected to:
1. Show stable vital signs
2. Have intact skin integrity
3. Maintain functional musculoskeletal system
4. Use effective method of communication
5. Participate in Activities of Daily Living (ADL’s) for self care
It is also expected that:
 Patient/family verbalize/ demonstrate knowledge and care skills about:
i. Disease process
ii. Need foe follow-up care/compliance
iii. Medications
iv. Proper feeding
v. Ambulation
vi. Transfer technique
could communicate his
condition to his caregiver.
Care for oneself could be
provided by the patient’s
significant other during the
time of hospitalization.
The patient, in relation to his
left side body weakness
could very likely experience
injury if not properly look
upon to.
Since the client experienced
a cerebro-vascular disease, it
was manifested through his
inability to feel sensation at
his left side body part.
This is the least priority for
the problems since this
would not be an immediate
need of the family and the
family could learn to adopt
to the condition of the
primary provider of their
family.
vii. Coping mechanisms/Support groups
XI. Nursing Care Plan
Nursing diagnosis
Cues Goal and Objectives Interventions Rationale Evaluation
and analysis

I Ineffective cerebral By the end of the Was the client able to

Before tissue perfusion nursing shift, the demonstrate
hospitalization: related to ischemia client will increased perfusion
demonstrate as individually
“mahilig akong Immediate cause: increased perfusion appropriate?
kumain nung mga Ischemia as individually __Y __N if N, why?
matataba.” appropriate. ____________
Intermediate Cause:
“nakakainom din ako Cerebro-Vascular Objectives:
ng 2-4 na bote ng gin Disease
sa isang araw.” After one hour of Effectiveness
Root Cause: nursing intervention,
Lifestyle Behavior the client will:
O
 Change in vital Health Implication: 1.identify factors Assess causative and An older client may Was the client able to
signs If cerebral blood flow related to present contributing factors. have lifestyle identify factors
 With slurred speech is inadequate, the condition patterns of inactivity related to present
 Change in motor amount of oxygen and high-fat diet that condition?
response (left-side supplied to the brain are risk factors; he or __Y __N if N, why?
body weakness) will decrease and she should be ____________
tissue ischemia will counseled.)Nursing
result. (Textbook of Diagnosis’ Application
M MedicaL Surgical to Clinical Practice
Vital signs (upon Nursing by Suzanne 10th ed. By Linda Juall
admission) Smeltzer 9th ed. Carpenito-Moyet p.
BP:140/80 p1655)…it may also 785)
RR:21 cycles per cause a wide variety
minute of neurological 2.display unchanged Monitor and Assesses trends in Was the client able to
CR:54 bpm deficits, dependent or improved document level of consciousness display unchanged or
T: 36.2ºC upon the location, neurological status neurological status and potential for improved
the size of the area and compare it with increased ICP and is neurological status?
of inadequate baseline. useful in determining __Y __N if N, why?
perfusion and the location, extent and _____________
amount of secondary progression/resolutio
blood n of CNS damage.
flow(p.1652)..if
complete ischemia
occurs and lasts for 3.exhibit stable vital Monitor vital signs Monitoring vital signs Was the client able to
more than 3 to 5 signs q1º or as necessary frequently helps note exhibit stable vital
minutes, the brain complications as soon signs?
will be irreversibly as they occur. ___Y __N if N, why?
damaged. (p. 1634) (McGraw-Hill Clinical _____________
Care Plans, Medical-
Surgical Nursing p.86)

Administer and Medications help

monitor effects of improve the clinical
medications condition of the
prescribed. client. (Fundamentals
of Nursing by Ruth F.
Craven p.524)

4. verbalize Instruct The dynamic nature Was the client/family

knowledge about client/family/SO of chronic conditions member/SO able to
needed therapeutic member about the necessitates verbalize knowledge
regimes(may also be need for: knowledge of how to about needed
manifested by the  Compliance balance one’s life to therapeutic regimes?
family member/SO)  Medications keep symptoms under __Y __N if N, why?
 Ambulation control as much as _____________
 Transfer possible. (Lubin,1995
technique p.473 of Nursing
 Proper feeding Diagnosis Application
to Clinical Practice)
Efficiency:
Were the strategies
suitable for given
time frame?
___Yes ___No

Appropriateness:
Were the selected
strategies/
interventions
appropriate to the
patient’s needs?
___Yes ___No
Adequacy:
Were the specific
learning objectives
and its content
enough to meet the
client’s needs ___Yes
___No

Acceptability:
Were the strategies/
interventions
acceptable for the
patient?
___Yes ___No
 NURSING CARE PLAN
NURSING NURSING
CUES ANALYSIS GOAL/ OBJ. RATIONALE EVALUATION
DIAGNOSIS INTERVENTION

I- “Hindi ko Impaired Immediate: Goal: Was the patient

maigalaw physical hemiparesis Within the able to maintain
ang kaliwang mobility r/t end of the a position of
parte ng hemiparesis nursing shift, the function by
katawan ko. Root: client will be maintaining or
” able to maintain increase strength
Cerebro-vascular a position of and function of
O- with disease function by affected and/or
numbness on maintaining or compensatory
one side of Health increase strength body part?
the body Implication: and function of __Y __N
Damage to affected and/or If N,
M- motor the CNS, damage compensatory Why___________
response: 5 to any body part. _
pts. out of 6 component of
the central Objectives:
nervous system 1. After 2 hours
that regulates of nursing
voluntary intervention, the
movement client will be
results in able to maintain
impaired body a position of
alignment and function as
mobility. The manifested by:
motor strip in Effectiveness
the cerebral a.) have a proper a.)- Change positions - Reduces risk of tissue
cortex can be body alignment at least every 2 hours ischemia/ injury. 1. Was the
damaged by (supine, sidelying) Affected side has patient able to
trauma from a and possibly more poorer circulation and maintain a
head injury, often if placed on reduced sensation and position of
ischemia from a affected side. is more predisposed to function
stroke or brain skin breakdown/ __Y __N
attack (CVA), or decubitus. If N,
bacterial - Position in prone Why___________
infection like position once/ twice - Helps maintain _
meningitis. a day if patient can functional hip
Motor tolerate. extension; however,
impairment is may increases anxiety,
directly related especially about ability
to the amount of to breathe.
destruction of (Nursing Care Plans for
the motor strip. Individualizing Patient
(Fundamentals Care by Doenges,
of Nursing by Moorehouse and
Potter and Perry, Geissler-Murr, 6th
6th edition, page edition, page 233)
1426)
b.) ability to b.)- Observe affected
Immobilization move within side for color, edema - Edematous tissue is
may lead to physical or other signs of more easily traumatized Was the client
emotional and environment compromised and heals more slowly. able to have the
behavioral circulation. ability to move
responses, within his
sensory - Inspect skin physical
alterations, and regularly, particularly - Pressure points over environment?
changes in over bony bony prominences are __Y __N if N,
coping. These prominences. Gently most at risk for why?_________
changes are massage any decreased
individualized to reddened areas and perfusion/ischemia
each client. provide aids such as circulatory stimulation
Common sheepskin pads as and padding help
emotional necessary. prevent skin breakdown
changes are and decubitus
depression, development.
behavioral (Nursing Care Plans for
changes, sleep- Individualizing Patient
wake Care by Doenges,
disturbances and Moorehouse and
impaired coping. Geissler-Murr, 6th
(Fundamentals edition, page 233)
of Nursing by
Potter and Perry, c.) perform ROM c.)- Begin
6th edition, page exercises with active/passive ROM - Minimizes muscle
1431) assistance to all extremities atrophy, promotes Was the client
(including splinted) circulation, helps able to perform
on admission. prevent contractures. ROM exercises
Encourage exercises Reduces risk of with assistance?
such as quadricepd/ hypercalciuria and __Y __N if N,
gluteal exercise, osteoporosis if why?_______
squeezing rubber underlying problem is
ball, extension of hemorrhage
fingers and legs/ Note: Excessive/
feet. imprudent stimulation
can predispose to
rebleeding.

- Assist to develop - Aids in retraining

sitting balance (e.g. neuronal pathways,
raise head of bed; enhancing
assist to sit on edge proprioception and
of bed, having motor response.
patient to use the
strong arm to support
body weight and
strong leg to move
affected leg, increase
sitting time and
standing balance
(e.g. put flat walking
shoes on patient, Appropriateness:
support patient’s Were the
lower back with selected
hands while strategies/
positioning own knees interventions
outside patient’s appropriate to
knees, assist in using the patient’s
parallel bars/ needs?
walkers. - Helps stabilize BP ___Yes ___No
(restores vasomotor
- Get patient up in tone), promotes Efficiency:
chair as soon as vital maintenance of Were the
signs are stable, extremities in a strategies
except following functional position and suitable for given
cerebral hemorrhage. emptying of bladder/ time frame?
kidneys, reducing risk ___Yes ___No
 of urinary stones and
infections from stasis. Adequacy:
Note: if stroke is not Were the specific
completed, activity learning
increases risk of objectives and its
additional bleed/ content enough
infarction. to meet the
client’s needs
___Yes ___No
- Prevents/ reduces
pressure on the coccyx/ Acceptability:
- Pad chair seat with skin breakdown. Were the
foam or water filled (Nursing Care Plans for strategies/
cushion and assist Individualizing Patient interventions
patient to shift Care by Doenges, acceptable for
weight at frequent Moorehouse and the patient?
intervals. Geissler-Murr, 6th ___Yes ___No
edition, page 233)
 Nursing Care Plan

Nursing diagnosis
Cues Goal and Objectives Interventions Rationale Evaluation
and analysis

Observation Impaired verbal Within the nursing Was the client able
communication shift, the patient to establish a
Unable to speak related to impaired will establish method of
dominant language cerebral circulation method of communication in
as manifested by communication in which needs can be
Speaks/verbalizes dysarthria and which needs can be expressed?
with difficulty impaired articulation expressed. __Y __N if N, why?
________
Difficulty in forming
words and sentences Immediate cause: Objectives:
Impaired cerebral
Unable to modulate circulation After 25 minutes of EFFECTIVENESS
speech nursing intervention,
Intermediate cause: the patient will be
Ischemia able to:

Root cause: 1)identify the need Assess type or degree Helps determine area Was the client able to
Cerebro-vascular for communication of dysfunction. and degree of brain identify the need for
disease involvement and communication?
difficulty the patient __Y __N if N, why?
Health Implication: has with any or all _____________
An aphasic person steps of the
may become communication
depressed because of process. Patient may
the inability to talk have trouble
to others. This understanding spoken
inability causes words, speaking
anger, frustration, words correctly or
fear of the future and may experience
hopelessness. damage to both
(Textbook of Medical- areas.
Surgical Bursing by (Doenges’ nursing
Suzanne Smeltzer 9th care plans)
ed. p. 1659)
2)express self, Listen for errors in Patient may lose Was the client able to
thoughts, and needs conversation and ability to monitor express self,
through gestures or if provide feedback verbal output and be thoughts, and needs
possible through unaware that through gestures or if
verbalization communication is not possible through
sensible. Feedback verbalization?
helps patient realize __Y __N if N, why?
why caregivers are _____________
not responding
appropriately and
provides opportunity
to clarify
content/meaning.
(Doenges)

3)demonstrate Have patient produce Identifies dysarthria, Was the client able to
communication simple words. because motor demonstrate
enhancement in components of communication
speech tasks speech can affect enhancement in
articulation and speech tasks?
may/may not be __Y __N if N, why?
accompanied by ______________
expressive aphasia.
(Doenges)

Provide alternative Provides for

methods of communication of
communication. needs/desires based
on individual
situation/underlying
deficit. (Doenges) EFFICIENCY:
Were the resources
Anticipate and Helpful in decreasing
provide for patient frustration when and strategies used
needs. dependent on others efficiently?
and unable to
communicate desires.
___Yes ___No
(Doenges)

Encourage SO/ It is important for APPROPRIATENESS:

visitors to persist in family members to Were the selected
efforts to continue talking to
strategies
communicate with patient to reduce
patient. patient isolation, appropriate the
promote client’s needs?
establishment of
effective
___Yes ___No
communication and
maintain sense of
connectedness with ADEQUACY:
family. (Doenges)
Were the objectives
and interventions
enough to meet the
client’s needs?

___Yes ___No

ACCEPTABILITY:

Were the
interventions
accepted by the
client?

__Yes __No