Subjective data :

Mr.Jamaan is 56 years old , male from Saudi Arabia. He is married. Known case of
diabetes mellitus and ischemic heart disease presented to ER complaining of left side
weakness for three days associated with headache to rule out acute insult , a case of
brain lesion , he underwent burr hole brain biopsy D20 . He is complaining of
weakness , limb , headache , he is on insulin every 6 hour to control his blood sugar.

Objective data :
The patient GCS is 15/15 . The Braden scale 19/23 . His vital signs as follow :
BP 137/58 – HR 79 – RR 19 – Temp 37 – his weight is 84.9 and his hight is 176 . The
BMI is 27.41 which consider as overweight . His appetite is good . Patient with round
head and short hear . His eyes is symmetry with both pupils that have same shape ,
size , and react equally to light , Conjunctiva is pink . The nose appeared symmetry ,
he has normal lung sound and normal breathing pattern . The patient with ascites .
The patient's skin white to yellow with discoloration in the chest and both arms. The
patient has no clubbing and normal capillary refill within 2 seconds. The patient has
no bowel movement for 4 days. Joint -and muscles are symmetric for both lower and
upper extremities. He has normal spinal , thoracic, and lumber , curvature. The patient
sleep for 5/6 hours with 30 minutes nap.
Diagnostic procedures :

Date The procedure Finding

09-2-2021 Chest CT -Atherosclerotic

calcific coronary
disease

- Left sided left

upper and
posterior vascular
collaterals .

09-2-2021 Abdomen and pelvis CT

- A right renal lower

pole simple cyst
measures 0.9 * 0.8
cm

- No free fluid in the

abdomen and
pelvis.no enlarged
lymph nodes.
4-2-2021 Brain CT There is complete ring
enhancing lesion measure
1.6*1.4 cm in AP and TR
dimensions respectively
noted at the right frontal
centrum semiovale
surrounded with vasogenic
edema
Laboratory results :
Time Laboratory test Finding Interpretation

1-3-2021 Hemoglobin 14.4 Normal

hemoglobin count.

1-3-2021 White blood cell 5.8 Normal white

blood cell.

1-3-2021 Albumin 35 Normal albumin

level.

1-3-2021 Urea nitrogen 4.1 Normal urea

nitrogen level

1-3-2021 Creatinine 58 Low creatinine

Level duo to low
body mass
1-3-2021 Glucose random 14.1 High glucose level
Hyperglycemia

1-3-2021 Hematocrit 44.6 Normal hematocrit

Level

1-3-2021 Platelet count 215 Normal platelet

level

1-3-2021 Alanine 34 Normal alanine

aminotransfere aminotransferase
level
Name of Dosage Frequency Route Time Action Side affect
medication

Metoprolol 50mg Take Oral 9:00Am Treat Stomach

Pain – vomiting-dry mouth
every 24 hypertensio – nausea
hours n
Nursing responsibility
Provide continual cardiac
monitoring for patients
receiving IV metoprolol.

Lisinopril 5mg Take Oral 9:00Am used to Dizziness- headache- dry

mouth – lightheaded
every 24 treat high
hours blood Nursing responsibility
Patients should be closely
pressure monitored in any case that
could result in a drop in
blood pressure due to a fall
in fluid volume.
atorvastatin 80mg Daily Oral 9:00Am Help lower Very serious allergic
problem and liver problem
bedtime bad
cholesterol Nursing responsibility
and high Administer the medication
at the same time every day,
good regardless of food.
cholesterol
Spironolactone 12.5mg Take Oral 9:00Am Used to treat Diarrhea- nausea- stomach
upset- vomiting
every 24 high blood
hours pressure and Nursing responsibility
heart failure Potassium-rich foods
should be avoided.

Isosorbide 5mg As needed Sublingual 9:00Am Used to Headache-dizziness-nausea

Lightheaded
prevent
chest pain Nursing responsibility
Potassium-rich foods
should be avoided.

Acetaminophe 1000mg As needed Oral 9:00Am Used to treat No side affect

n mild to
moderate
pain
Nursing care plan

Nursing diagnosis Goal Nursing intervention Evaluation

Risk for injury The patient will not Keep the patient The patient didn’t
related to altered show sign of damage environment easy to show signs of
sensory reception caused by sensory minimize sensory damage caused by
defect overload and allow sensory defect
visual signals to be
focused
Risk for infection Patient demonstrate Asses sign and Patient has no signs
related to break skin no sign and symptom of of infection
integrity symptom for infection; fever ,
infection WBC
Impaired oral Improve the status Use tap water or Patient with
mucous membrane of oral mucous normal saline to mucositis stage 2
related to side effect membrane provide oral care
of lisinopril
Anxiety related to Reduce anxiety and Interact with patient Patient feeling
change in health encourage in a peaceful manner stability increases in
status expression feelings calm