1. Make an admitting nurses’ notes using the FDAR Charting?

- charting notes should be reflected from: (3 shifting notes)

Admission (ER) admitting notes
Endorsement from ER --> Neuro-medical Unit
Ward (endorsement ---> to the next shift (3-11 PM); ---> 11- 7 AM shift)

Date/Time FOCUS NURSING NOTES

SHIFT

9/2/21 ---------------------------------------- Emergency Room Notes -------------------------------------------

Impaired Physical ‣ Admitted female 70 years old; white shirt, red pants; weight 131 lbs and height 5’6;
Mobility related to accompanied by daughter; awake, confused, SOB.--------------------------—Alliah Ruiz, RN
10:25 AM hemiplegia D‣ V/S as follows: BP- 150/95 mmHg, RR- 16 bpm, HR- 98 bpm
10:30 AM A‣ Assisted in transfer to stretcher; Referred to ER physician; Physical examination
done, has pain in her left arm, a slight headache, slight carotid bruits on the right; NIHSS
was done and results showed left hemiparesis and left visual/spatial neglect.
10:35 AM ‣ All consent forms have been read and signed; Requested the following laboratory
exams: CBC, Prothrombin time, serum electrolytes levels, cardiac biomarkers,, and renal
function studies; CT Scan and Cerebral Angiography.
10:40 AM ‣ Relayed results to the referred consultant neurologist specialist by the ER primary
physician as laboratory examination results were shown.
12:10 PM ‣ As per doctor’s order, Started IV fluid of PNSS at the left arm regulated at 1L 20 gtts
and intravenous rt-PA (thrombolytic therapy) at a dose of 0.9 mg/kg and attached to
infusion pump; Antiplatelet therapy will start at an initial dose of Aspirin 325 mg, 24 hours
after thrombolytic therapy, and a maintenance dose of 75 mg per day.
12:15 PM ‣ Advised for admission to Neurologic Unit; Informed Neuro unit out admission of patient
12:20 PM ‣ Assessed physical condition; Explained the transfer to patient and S/O to Neuro Unit;
Maintained physical well-being during transport (side rails up); Assisted in arrival to
Neuro unit; Announced arrival to the new unit; Transported to a new room and assisted in
transfer to bed; Provided verbal report about the condition to the receiving unit nurse.
12:30 PM R‣ Complete blood count, Prothrombin time, serum electrolyte levels, cardiac
biomarkers, and renal function studies are within normal limits; CT scan of the brain
indicates a thrombus in a branch of the right internal carotid artery, with approximately
50% occlusion due to atherosclerosis; Area of infarction in the right anterior hemisphere
and there is no evidence of a subarachnoid hemorrhage; Endorsed to Neuro-medical
 unit; Handover of nurses notes.————————————————————— A.R,RN

---------------------------------------- Neuro-Medical Ward Notes ---------------------------------------

‣ Received in stretcher, awake; with IV rt-PA @ 0.9 mg/kg ------------ Ruhaina Jawad, RN
Impaired Physical D‣ V/S as follows: BP- 148/92 mmHg, RR- 16 bpm, HR- 94 bpm; T- 37.2°C; NIHSS
12:30 PM Mobility related to result to left hemiparesis and left visual/spatial neglect; CT scan of the brain indicates a
hemiplegia thrombus in a branch of the right internal carotid artery, with approximately 50%
occlusion due to atherosclerosis; Area of infarction in the right anterior hemisphere.
A‣Transferred on bed comfortably; Changed to hospital gown; V/S rechecked: 140/90
mmHg, RR- 16 bpm, HR- 90 bpm; T- 37.2°C; Monitored and recorded IV rt-PA.
12:35 PM ‣ Observed affected side for color, edema, or other signs of compromised circulation.
‣ Inspected skin regularly, particularly over bony prominences; Gently massaged any
12:45 PM reddened areas and provided aids such as sheepskin pads as necessary. -------------------
1:00 PM ‣ Placed pillow under axilla to abduct arm to prevent adduction of shoulder and flexion of
elbow; Elevated arm and hand to promote venous return and help prevent edema
1:45 PM formation; Placed knee and hop in extended position to maintain functional position.
‣ Changed positions every 2 hr (supine/side lying), more often if placed on the affected
side. --------------------------------------------------------------------------------------------------------------
2:45 PM R‣ V/S taken as follows: 140/90 mmHg, RR- 15 bpm, HR- 88 bpm; T- 37.2°C; no edema
formation and other signs of compromised circulation; no signs of adduction of shoulder
3:00 PM and flexion of elbow; maintained in functional position; endorsed to next NOD— R.J,RN

-------------------------------Neuro-Medical Ward Notes 3-11PM----------------------------------------

‣ Received patient in a ward room, awake; with IV rt-PA @ 0.9 mg/kg; in a hospital gown
3:00 PM ---------------------------------------------------------------------------------------Almena Ladjamatli, RN
Impaired Physical D‣ V/S taken as follows: 140/90 mmHg, RR- 15 bpm, HR- 88 bpm; T- 37.2°C; no edema
Mobility related to formation and other signs of compromised circulation; no signs of adduction of shoulder
hemiplegia and flexion of elbow; maintained in functional position;----------------------------------------------
A‣ V/S rechecked: 137/90 mmHg, RR- 17 bpm, HR- 89 bpm; T- 37.0°C; Monitored and
3:35 PM recorded IV rt-PA.----------------------------------------------------------------------------------------------
‣ Maintained leg in neutral position with a trochanter roll to prevent external hip rotation;
4:00 PM Placed hard hand-rolls in the palm with fingers and thumb opposed to decrease the
stimulation of finger flexion, maintained finger and thumb in a functional position.-----------
‣Inspected skin regularly, particularly over bony prominences; Gently massaged any
4:30 PM reddened areas and provided aids such as sheepskin pads as necessary---------------------
‣ Administered medication of Atorvastatin 20 mg 1 tab; Gently inserted the catheter into
 5:00 PM the urethra opening until urine begins to flow out, as per doctor’s order.------------------------
‣ Changed positions every 2 hr (supine/side lying), more often if placed on the affected
side.----------------------------------------------------------------------------------------------------------------
‣ Assessed with the NIHSS; Assessed extent of impairment initially and on a regular
5:20 PM basis. Classified according to 0–4 scale; Evaluated the patient's risk for complications ----
‣ Assessed with the Berg Balance Scale; Instructed to Lift arm to 90 degrees and stretch
6:00 PM out her fingers and reach forward as far as she can. (Placed a ruler at the end of
fingertips when the arm is at 90 degrees; fingers should not touch the ruler while
reaching forward.) --------------------------------------------------------------------------------------------
‣ Assisted while taking the Stops Walking When Talking test; Assisted to develop sitting
6:45 PM balance by raising head of bed, assisted to sit on edge of bed, using the strong arm to
support body weight and move using the strong leg; Assisted to develop standing
balance by putting flat walking shoes, supporting lower back with hands while positioning
own knees outside knees, assisted in using parallel bars; -----------------------------------------
‣ Changed positions every 2 hr (supine/side lying), more often if placed on the affected
8:00 PM side.----------------------------------------------------------------------------------------------------------------
‣ V/S rechecked: 135/90 mmHg, RR- 15 bpm, HR- 87 bpm; T-
9:00 PM 37.4°C;-------------------------
‣ Monitor Intake &
11:00 PM output-------------------------------------------------------------------------------------
R‣ V/S rechecked: 140/90 mmHg, RR- 17 bpm, HR- 90 bpm; T- 37.0°C; NIHSS-12;
cognitive and communication skills are intact; Berg Balance Scale-43; Patient does stop
walking to engage in conversation; (CES-D) Scale-no sign of depression; no signs of
external hip rotation; no signs of increased stimulation of finger flexion and other signs of
functional position; endorsed to next NOD----------------------------------------------------A.L, RN

------------------------------------Neuro-Medical Ward Notes11-7am -------------------------------------

Date/Time Shift Impaired Physical -Received in a ward room, awake; lying in a supine position;with IV rt-PA @ 0.9 mg/kg; in
Mobility related to a hospital gown; with foley catheter attached ------------------------------------- Saima Taradji,
11:00pm hemiplegia RN
D: V/S as follow:140/90 mmHg, RR- 17 bpm, HR- 90 bpm; T- 37.0°C; NIHSS-12; cognitive
and communication skills are intact; Berg Balance Scale-43; does stop walking to engage
 in conversation; (CES-D) Scale-no sign of depression; no signs of external hip rotation; no
signs of increased stimulation of finger flexion and other signs of functional
position;---------------------------------------------------------------------------------
11:35pm A: V/S rechecked: 135/90mmHg, RR-19 bpm, HR-90 bpm, T-37.0°C; NIHSS-12; cognitive
and communication skills are intact; Berg Balance Scale-43;(CES-D) Scale-no sign of
depression are present.---------------------------------------------------------------------------------
12:30am -Refer to stroke rehabilitation team and multidisciplinary rehabilitation team ; Initial
medical assessment done;All consent forms have been read and signed by the patient
1:00am families; collaborated with the rehabilitation team to assess the patient rehabilitative
needs;-------------------------------------------------------------------------------
- Assessed the NIHSS scale score; Assessed extent of impairment initially and on a
regular basis, classified according to 0–4 scale; Assessed the patient with the Berg
Balance Scale; Instructed the patient to Lift her arm to 90 degrees and stretch out her
1:35am fingers and reach forward as far as she can. (Placed a ruler at the end of fingertips when
the arm is at 90 degrees. Fingers should not touch the ruler while reaching
2:45am forward).------------------------------
-Collaborated with the rehabilitation team to develop and assist the patient in using
assistive devices to achieve activities of daily living as independently as possible.-------------
3:15am
-Assisted with exercise and performed ROM exercises for both the affected and unaffected
sides; Encouraged to touch the paralyzed side and to participate in passive ROM
exercises as appropriate.--------------------------------------------------------------------------------------
-Assisted while taking the Stops Walking When Talking test; Encouraged to develop sitting
3:55am balance by raising head of bed, assisted to sit on edge of bed, using the strong arm to
support body weight and move using the strong leg. Assisted to develop standing balance
4:00 am by putting flat walking shoes, supporting lower back with hands while positioning own
knees outside patient’s knees, assisted in using parallel bars;--------------------------------------
- Changed positions at least every 2 hr. (supine, side lying) and possibly more often if
4:35am placed on the affected side.---------------------------------------------------------------------------------
- Taught how to use a walker, cane, or wheelchair as appropriate; Discussed the
5:55am necessary home adaptation to S/O such as wheelchair ramp, shower seat, bathroom
modifications.
- Ensured the correct positioning to prevent contractures, preventing hip reduction by
6:30am positioning on side with hips slightly flexed and in as natural position as possible; used
prone position if possible; and prevented shoulder adduction by placing pillow in the axilla.
 -Discussed the program with S/O and explained the course of rehabilitation and the
7:00am expectations; Rehabilitation will focus on an exercise program consisting of aerobic
exercise, such as walking, and coordination and balance activities .-------------------------------
-Coordinated with the rehabilitation team to provide discharge instructions to the patient to
continue at home and recommend some activity as a secondary preventive measure.
--------------------
R- V/S rechecked: 130/90mmHg, RR-16 bpm, HR-89bpm, T-37.0°C; NIHSS-5; cognitive
and communication skills are intact; Berg Balance Scale-56;(CES-D) Scale- no sign of
depression; no signs of external hip rotation; no signs of increased stimulation of finger
flexion and other signs of functional positions.--------------------------------------------------ST, RN
2. Transcribe all orders in the Doctor's sheet, medication sheet, fluid sheet and other flow sheet. (may utilize downloadable forms or
forms given to you by previous CI duty.)

MEDICATION SHEET

Name: Patient B

Attending Physician: Doctor P

Age: 70 years old

Ward: Neuro unit

Room No: 7

MEDICATION FREQUENCY & ROUTE TIME DATE & INITIAL

rt-PA (Thrombolytic therapy) 0.9 mg/kg IV 12:10 pm 9/2/21

AR. RN

Aspirin 325 mg PO 12:10 pm 9/2/21

AR. RN

Atorvastatin 20mg 1 tab 12:10 pm 9/2/21

AR. RN

Plain Normal Saline Solution 1L 20 drops per 12:10 pm 9/2/21

minutes AR. RN
Side Notes Doctor’s Order Sheet C A R E D Time/Sign In

9/2/21 > request for CBC; Prothrombin time; serum ✔ 10:40 am (A.R.)

10:35 am electrolytes levels, cardiac biomarkers, and renal

function studies - ASAP; for CT Scan of the brain and

Cerebral Angiography;

12:10 pm > Start with intravenous rt-PA (thrombolytic therapy) at ✔ 12:12 pm (R.J.)

a dose of 0.9 mg/kg;

- antiplatelet therapy at initial dose of Aspirin 325 mg ✔ 7:00 am (S.T.)

9/3/21

24 hours after thrombolytic therapy

- (maintenance dose of 75 mg per day) ✔ 7:00 am (S.T.)

9/3/21

12:15 pm > Advised for admission at Neuro-medical ward once ✔ 12:16 pm (A.R.)

stable.

5:00 pm > Atorvastatin 20 mg 1 tab. daily ordered for ✔ 5:05 pm (A.L.)

referral to stroke rehabilitation.

> catheter insertion ✔ 5:05 pm (A.L.)

VITAL SIGNS MONITORING SHEET

Patient Name:Patient B
Age: 70 years old
Ward: Neuro unit
Room No: 7
Attending Physician: Doctor P

Date/Time B/P HR RR TEMP REMARKS

9/2/21
10:25am 150/95mmHg 98bpm 16bpm 37.6°C

12:30pm 148/92mmHg 94bpm 16bpm 37.2°C

3:00pm 140/90mmHg 88bpm 15bpm 37.2°C

3:35pm 137/90mmHg 89bpm 17bpm 37.0°C

9:00pm 135/90mmHg 87bpm 15bpm 37.4°C

11:00pm 140/90mmHg 90bpm 17bpm 37.0°C

11:35pm 135/90mmHg 90bpm 19bpm 37.0°C

7:00am 130/90mmHg 89bpm 16bpm 37.0°C

PATIENT’S KARDEX

Name: Patient B Age: 70 years old Sex: Female Civil Status: Widow Hospital No. 7
Address: La Purisima Street, Zamboanga City Religion: Roman Catholic
Chief Complaint: Unconscious, collapsed and SOB Diet:
Clinical Impression: Acute ischemic stroke
Date of Admission: September 2, 2021 Date of Discharge:

MEDICATIONS: SPECIAL PROCEDURE/ENDORSEMENT

● rt-PA (Thrombolytic therapy) 0.9 mg/kg IV ● Maintenance dose of 75 mg per day

● Aspirin 325 mg PO ● Assessed with the Neurologic Institute Health Stroke Scale
 ● Atorvastatin 20mg 1 tab (NIHSS)
● Plain Normal Saline Solution 1L 20 drops per minutes ● Monitor Neuro Vital Signs (NVS). Daily.
● Dr. O ordered for referral to stroke rehabilitation, and a
multidisciplinary rehabilitation team

INTRAVENOUS FLUID SHEET

Name:Patient B Age:70 Room No:7

Attending Physician:Doctor P Ward: Neuro Unit Hospital No:
Bottle No. Type of Solution, Volume in cc Date & Time Rate of flow Date & Time
Drug incorporated Started/ Initial Ended/ Initiated
and Others

1 Plain NSS 1000cc 12:10 pm 20 drops per minutes

24 - HOUR INTAKE-OUTPUT RECORD

Name:Patient B Age:70 Room No:7

Attending Physician:Doctor P Ward: Neuro Unit Hospital No:

INTAKE OUTPUT
Date:
SHIFT ORAL NGT OTHERS 8 HRS SHIFT URINE OTHERS 8 HRS SIGN
TOTAL TOTAL

7-3 - 7-3

3-11 - 3-11

11-7 - 11-7

24HRS - 24HRS
TOTAL TOTAL
3. As an ER head Nurse what are your nursing responsibilities and duties in the area of assignment? also as a staff nurse know your
duties and responsibilities.

Duties and Responsibilities of Head Nurse:

● Ensures the highest standard of clinical care is maintained, utilizing a systematic approach to nursing.
● Reviews and updates nursing policies, practices, procedures and recommends improvements.
● Coordinates probationary period for new hire staff by allocating appropriately skilled and knowledgeable preceptors, evaluating new
staff fortnightly and implementing Developmental Plans when necessary
● Actively manages staff performance and completes objective staff Performance Appraisals both probationary and annual.
● Actively implements Quality Assessment and Improvement Activities within the guidelines and standards of the Nursing
Department.
● Facilitates the integration of standards of patients care specific to the unit and ensures the dignity and rights of patients are
respected.
● Maintains and updates required unit/clinic documentation/records in accordance with Government/Hospital and Quality Department
requirements.
● Responsible for ordering new equipment and ensures effective utilization, maintenance, inventory and storage of equipment.
● Initiates and maintains risk management assessment and performed improvement activities by unit level.
● Develop and submits unit goals and establish unit/group norms based on input from the staff and identified needs.
● Conducts regular monthly ward meetings which include quality improvement and educational activities.
● Participates in short and long range planning for and development of the patient care unit.
● Prepare monthly and semi-annual accountability reports and submits to the Supervisor.
● Maintains updated staff personal information and licensure.
● Oversees and coordinates the patient’s plan of care and monitors multidisciplinary patient care activities to assure quality in patient
care.
● Assure nursing care activities are delegated appropriately according to the level of staff education, skills and abilities in accordance
to the patient needs and acuity.
● Evaluates nursing care and nursing documentation through daily unit/area rounds and on going observation of patient care and unit
operations and makes and changes in nursing practice base on clinical judgment and current practice.
● Facilitates the integration of standards of patients care specific to the unit and ensures the dignity and rights of patients are
respected.
● Participates in short and long range planning for and development of the patient care unit.
● Renders direct patient care and functions as charge nurse when necessary.
 ● Maintains the control, storage and administration of drugs including narcotics.
● Promotes and participates in health education for patients and relatives.
● Maintains safe patient ratio and skills mix.
● Coordinates and monitors staff activities related to patient care.
● Reviews patient medical records for accurate and timely documentation.
● Act as a positive role model and exhibits leadership in the promotion of a professional practice environment.
● Plans and actively participates in staff educational development.
● Identifies staff potential for promotion, development or special assignment or expanded roles.
● Initiates corrective action as appropriate with support from Nursing Administration and personnel.
● Maintain unit’s disaster and fire preparedness and ensures all staff are knowledgeable and competent in the related procedures.
● Assist and guides the staff in the documentation of unusual occurrences and incidents.

https://alsalamhospital.com.sa/head-nurse-emergency-room-er/

Emergency Room Staff Nurse

Triage An emergency room nurse helps staff prioritize care based on the critical nature and severity of a patient’s condition. A nurse’s
medical knowledge, quick thinking, and attention to detail lend a hand towards comprehensively assessing a patient’s needs, obtaining
their medical history and personal information, and seeking a doctor’s evaluation immediately for life-threatening issues.

Taking vital signs Logging vital statistics is a staple responsibility of an emergency room nurse. Taking vital signs includes recording a
blood pressure reading with a blood pressure pump, as well as measuring pulse rate, respiration, and temperature over the course of a
patient’s stay in the E.R. Vital signs provide a bird’s eye view of a patient’s state and alert nurses to changes in condition which might
require a doctor’s attention.

Administering medicine Once prescribed by a doctor, a nurse will be the one to legally administer medicine, whether it is in setting up
and priming an intravenous (IV) infusion or handing over pills for swallowing with water. Sometimes E.R. patients will already be on existing
medication which needs to be administered during their stay there. Nurses will confirm current medication lists with patient and family (or
call on the hospital pharmacist to) and acquire in-hospital prescriptions from the E.R. doctor for those medicines.

Providing treatment In addition to dosing meds, emergency room nurses may help with medical treatment for everything from sore
throats to kidney infections. Nurses may also assist with minor medical procedures as part of the treatment response, helping to stabilize a
patient and assist the doctor with everything from suturing wounds to intubating critical patients.
Monitoring patients Nurses are responsible for overseeing follow-through on doctor’s orders, from making sure medications are given to
checking on completion and results of diagnostic tests that are ordered. While lab techs typically transport a patient in their bed to a
diagnostic test, i.e. an x-ray or CT, when staff is short-handed, a nurse may be asked to assist. If a patient’s condition changes or worsens
while they are in the E.R., nurses are in charge of notifying the doctor right away. Patients and their families may make requests for simple
things like another blanket or a snack, and nurses bear the responsibility of fielding these requests and keeping the patient comfortable.

Charting Emergency room nurses are required to chart all patient medical history, contact information, current condition and medications,
and treatment as well as update their electronic medical record throughout their stay in the E.R. Accurate documentation in a patient’s chart
gives other members of the medical team correct information to act on throughout the patient evaluation and treatment journey. Efficient
and vigilant charting also protects hospitals and staff from potential legal liability down the line.

Discharge When a patient does not require being admitted to the hospital and is deemed ready to leave the emergency room after
treatment, their emergency room nurse handles the discharge paperwork, explaining it to the patient and their family/caregiver, and
answering any questions they may have. They also confirm transportation from the E.R. with the patient, their destination (especially if they
are going to a rehab or assisted living facility), and follow-up recommendations for care and doctor’s visits.

https://emedcert.com/blog/key-responsibilities-of-an-emergency-room-nurse

4. What is the demographic profile of the patient? 5. Utilizing the nursing assessment present the case in an orderly manner (base
from the scenario given): TAHAJID

a) What is the demographic profile of the patient?

● Name: Patient B
● Age: 70 years old
● Sex: Female
● Marital Status: Widow
● Address: La Purisima Street, Zamboanga City
● Religion: Roman Catholic
● Occupation: Retired Teacher
● Attending Physician: Dr. P
● Date of Admission: September 2, 2021
 b) What is the chief complaint of patient upon admission?

● Chief complaints: Unconscious, collapsed and SOB

c) Patient history of present illness?

● Prior to arrival, Patient B lost consciousness and collapsed at home, and was found by her daughter on the floor,
awake, confused, and slightly short of breath. The daughter reports that her mother had an episode of sudden-onset
numbness and tingling in the right limb, with slight confusion and slurred speech, 3 days previously. The EMS
evaluated Patient B, drew blood for a glucose level, and determined that she may have had a stroke. For this, she was
immediately brought to the nearest comprehensive stroke center.

d) Patient past illness and medical history?

● Patient B has been treated for hypertension for 10 years but notes that she is often not compliant with her anti-
hypertensive medicine, a diuretic as verbalized by her daughter.

e) Social history?

● The patient has never smoked, and drinks occasionally

6. Cluster the presented manifestations to subjective and objective signs. YU

Subjective Objective

“When I opened the door, I saw my mom lying on the floor ● Decreased Level of Consciousness
looking confused and she was also having a hard time ● Shortness of breath
breathing,” as verbalized by the patient’s daughter. ● Pain @ left arm
● Headache
● Carotid bruits on the right
 ● NIHSS revealed left hemiparesis and left visual/spatial
neglect with a score of 12
● CT scan shows a thrombus in a branch of the right internal
carotid artery, with approximately 50% occlusion due to
atherosclerosis; area of infarction in the right anterior
hemisphere
● Berg Balance Scale: 43
● Stops Walking When Talking Test (+)
● Had history of an episode of sudden-onset numbness and
tingling in the right limb, with slight confusion and slurred
speech.
● Hypertensive for 10 years

Vital Signs:
● BP: 50/95 mm Hg
● RR: 16 bpm
● HR: 16 bpm

7. What significant information contribute to clients’ present condition? SAALAN

- Patient B has been treated for hypertension for 10 years but notes that she is often not compliant with her antihypertensive
medicine, a diuretic. Hypertension is the most significant risk factor for stroke. Hypertension means that the blood is exerting
more pressure and overtime, this weakens and damages the blood vessel walls, which can lead to stroke, particularly
cerebral hemorrhage. Hypertension may also cause thickening of the artery walls, resulting in narrowing and eventually
blockage of the vessels. Antihypertensive medications are maintenance to help control blood pressure, and since the patient
is noncompliant in her maintenance med, stroke will likely happen.
- 3 days Prior to Arrival (PTA), Patient B had an episode of sudden-onset numbness and tingling in the right limb, with slight
confusion and slurred speech for 5 minutes. This is the 1st stage of CVA: Transient ischemic attack. Transient ischemic
attack (TIA) is a temporary period of symptoms similar to those of a stroke. A TIA usually lasts only a few minutes and doesn't
cause permanent damage. Often called a ministroke, a transient ischemic attack may be a warning sign for stroke. However
after experiencing this, the patient did not inform her primary care physician.
8. Identify medical/diagnostic/laboratory/surgical management that contribute to client’s care. Discuss what is the implication to
client’s present situation? SANTIAGO

➢ CT scan & Cerebral Angiography

- Helped assessed the location of the infarction (caused by a thrombus) and presence of vessel occlusion

➢ IV rTPA & Antiplatelet therapy

- Helped dissolve blood clots that can lead to recurrent episodes of stroke and heart attack given that the patient is not
compliant with her anti-hypertensive medications

➢ Rehabilitation mainly physical therapy

- Helped the patient relearn simple motor activities and ability to function independently.

9. What preparation needed for Patient B who will undergo diagnostic test includes cerebral Angiogram and MRI. (present during
online synchronous session) RUIZ & YU

Cerebral Angiogram

BEFORE THE PROCEDURE

- Secure informed consent.

- Advise patient to not eat or drink for 8 hours.
- Halt medications contraindicated with the procedure.
- Administer mild sedative and fluids through IV as ordered.
- Position the patient on the x-ray table.
- Place the blood pressure cuff, heart monitor, and pulse oximeter on the patient to monitor their vital signs.
 - Drape the patient’s body.

DURING THE PROCEDURE

- Reassure the patient.

- Instruct the patient on how to properly breathe and swallow while taking the x-rays.

AFTER THE PROCEDURE

- Monitor vital signs.

- Check the incision site.
- Instruct the patient to lie still with his or her head flat for six to eight hours.
- Instruct patient to slowly get out of bed to prevent lightheadedness and dizziness.
- Advise patient to avoid heavy lifting, exercise, and driving for 48 hours after the procedure.It is important not to stress the
incision/puncture site.
- Instruct patient to drink plenty of fluids to flush the contrast dye from the kidneys for the next 24 hours and to avoid beverages
that dehydrate the body, such as alcohol or coffee.

https://www.atlantabrainandspine.com/diagnostic-tests/cerebral-angiogram/

MRI

BEFORE THE PROCEDURE

- Secure informed consent.

- Explain the procedure to the client.
- 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.
- Administer a mild sedative to reduce anxiety.
- Place the patient in a supine position.

DURING THE PROCEDURE

 - Reassure the patient.
- Remind the patient to remain still throughout the procedure.
- Provide comfort measures and pain medication as needed and ordered because of prolonged positioning in the scanner.
- If the test is prolonged with the patient lying flat, monitor for orthostatic hypotension.

AFTER THE PROCEDURE

- Monitor vital signs.

- Monitor the patient for orthostatic hypotension.
- Advise the patient to resume his normal diet and activities unless otherwise indicated.

https://www.rnpedia.com/nursing-notes/medical-surgical-nursing-notes/magnetic-resonance-imaging/

10. List down the drugs given to patient and conduct a drug study and give its significance to client care. (make a medication card
for each drug) ABDURASAD

MEDICATIONS:

● rt-PA (Thrombolytic therapy) 0.9 mg/kg IV

● Aspirin 325 mg PO
● Atorvastatin 20mg 1 tab
● Plain Normal Saline Solution 1L 20 drops per minutes
 Mechanism of
Drug Indication/Contraindication Nursing Responsibilities
action/Side effect

Brand Name: Lipitor Mechanism of action: Indications:  Instruct patient to take medication
LIPITOR lowers plasma Lipitor is a prescription medicine as directed. If a dose is missed,
Generic Name: cholesterol and used to lower blood levels of “bad” omit and resume usual schedule
Atorvastatin lipoprotein levels by cholesterol (low-density with next dose.
Calcium inhibiting HMG-CoA lipoprotein, or LDL), to increase  Do not double up on missed doses.
reductase and levels of “good” cholesterol (high- Advise patient to avoid drinking
Classification: cholesterol synthesis in density lipoprotein, or HDL), and more than one quart of grapefruit
HMG-CoA the liver and by to lower triglycerides and to treat juice or 2 glasses of alcohol per
Reductase Inhibitors, increasing the number the symptoms of high cholesterol day during therapy.
Lipid-Lowering of hepatic LDL (hyperlipidemia) and to lower the  Advise patient that this medication
Agents, Statins receptors on the cell- risk of stroke should be used in conjunction with
surface to enhance diet restrictions (fat, cholesterol,
Route: Oral uptake and catabolism Contraindication: carbohydrates, alcohol), exercise,
of LDL ● Atorvastatin is and cessation of smoking.
Dosage: 10 to 80 mg contraindicated in patients  Instruct patient to notify health
Side effects: with active hepatic disease care professional promptly if
Frequency: OD ● constipation, (including cholestasis, unexplained muscle pain,
● diarrhea, hepatic encephalopathy, tenderness, or weakness occurs,
● nausea, hepatitis, and jaundice) or especially if accompanied by fever
● fatigue, unexplained persistent or malaise. Also notify health care
● gas, elevations in serum professional if signs of liver
● heartburn, aminotransferase problems (feeling tired or weak;
● headache, and. concentrations. loss of appetite; upper belly pain;
● mild muscle pain. dark urine; or yellowing of skin or
whites of eyes).

Mechanism of
Drug Indication/Contraindication
action/Side effect
Brand Name: Mechanism of action: Indications:
Zorprin, Bayer Aspirin works by
Buffered Aspirin, irreversibly inhibiting
Durlaza the enzyme cyclo-
oxygenase (COX-1)
Generic Name: which is required to
Aspirin make the precursors of
thromboxane within
Classification: platelets. This reduces
Antiplatelet Agents, thromboxane synthesis.
Cardiovascular; Thromboxane is
 Instruct patient to notify health
care professional of all Rx or OTC
medications, vitamins, or herbal
products being taken and to
consult health care professional
before taking any other Rx, OTC,
or herbal products.
 Advise patient to notify health
care professional of medication
regimen prior to treatment or
surgery.
Nursing Responsibilities
 For patients who have had oral or
 Angina pectoris. dental surgery or tonsillectomy in
 Angina pectoris the last seven days avoid chewable
prophylaxis. or dispersible aspirin tablets, or
 Ankylosing spondylitis. aspirin in crushed tablets or
 Cardiovascular risk gargles.
reduction.  Assess pain and/or pyrexia one
 Colorectal cancer. hour before or after medication.
 Fever.
 In long-term therapy monitor renal
 Ischemic stroke.
 Antiplatelet Agents, required to facilitate  Ischemic stroke: and liver function and ototoxicity.
Hematologic; platelet aggregation and Prophylaxis.  Assess other medication for
NSAIDs; Salicylates to stimulate further possible interactions - especially
platelet activation. Contraindication: warfarin which is a special hazard.
Route: Oral ● systemic mastocytosis.  Be aware that aspirin is a common
Side effects: ● low vitamin K levels. constituent of a variety of over-
Dosage: 50-325 ● conditions of ● a type of joint disorder due to the-counter medications.
mg/day orally within excess stomach excess uric acid in the blood
48 hours of stroke or acid secretion.
called gout.  Nurses should refer to
TIA, then 75-100 ● irritation of the ● anemia. manufacturer’s summary of
stomach or
mg/day orally ● hemophilia. product characteristics and to
intestines.
● a decrease in the blood appropriate local guidelines
● nausea.
Frequency: TID clotting protein prothrombin.
● vomiting.
(depending on case) ● blood clotting disorder - von
● heartburn.
Willebrand's disease.
● stomach cramps. ● decreased blood platelets.

11. Identify top 3 priority problems base from the scenario given and Formulate a comprehensive NCP. ONG
 Assessment Nursing Plan of care Intervention Evaluation
diagnosis

Subjective: At the end of 24 hours -Establish rapport with the After 24 hours of nursing
“had an episode of nursing patient and family. interventions, the goal
of sudden-onset interventions, the Rationale: to promote was met. The patient was
numbness and patient will be able to: cooperation able to:
tingling in the -Monitor vital signs
right limb, with Risk for injury -Understand the risk Rationale: to have a -Understood the risk
slight confusion related to factors that contribute baseline data factors that contribute to
and slurred altered mobility to possibility of falls -Keep the side rails of the possibility of falls
speech, 3 days due to stroke -seek help to perform bed raised -sought help to perform
previously.” as tasks that are beyond Rationale: to protect from tasks that are beyond her
reported by her her capabilities falling out of bed capabilities
daughter -remain free from -Assist patient in her ADLs -remained free from injury
injury AEB absence of Rationale: to avoid patient AEB absence of
Objective: abrasion/falls from injury abrasion/falls
-Left hemiparesis -Inform patient’s guardian
-Berg Balance not to leave her in the
Scale of 43 bathroom/room alone
Rationale: for continuous
monitoring and guidance

Assessment Nursing Plan of care Intervention Evaluation

diagnosis
Subjective: At the end of 24 hours -Establish rapport with the At the end of 24 hours
“had an episode nursing interventions, patient and family. nursing interventions, the
of sudden-onset the patient will be ableRationale: to promote goal was partially met.
numbness and Impaired to: cooperation the patient was able to:
tingling in the physical mobility -Determine the degree of
right limb, withrelated to Short term: Increase immobility -Demonstrated resumption
slight confusionneuromuscular physical mobility Rationale: to establish of activities and
and slurred involvement as (affected side) comparative baseline -Participated in ADL’s with
speech, 3 days evidenced by -Demonstrate -Observe movement when assistance of the
previously.” as left hemiparesis resumption of activities patient is unaware someone due to
reported by her -Participate in ADL’s Rationale: to note any hemiparesis on her left
daughter -Maintain or increase incongruence with the reports of side
muscle control abilities -Slowly maintained and
Objective: -Maintain skin integrity -Support affected part with shown increased muscle
-Left pillows control
hemiparesis Long term: Rationale: reduce the risk of -Maintained skin integrity
-NIHSS score of Participate in pressure ulcers -Verbalized understanding
12 therapeutic regimen -Inspect skin regularly, of the situation
-Does stop -Verbalize particularly over bony -Verbalized the
walking to understanding of the prominences. understanding of therapy
engage in situation Rationale: Pressure points over needed
conversation -Verbalization of bony prominences are most at -Participated in the
understanding the risk for decreased perfusion. interventions rendered by
therapy need -Give rest periods to activities the nurse
-Able to participate in Rationale: to help reduce
the interventions fatigue and O2 demand
rendered by the nurse -Encourage adequate fluids and
right diet as necessary
Rationale: to increase energy
production
 Assessment Nursing Plan of care Intervention Evaluation
diagnosis

Subjective: At the end of 24 hours -Establish rapport with the patient At the end of 24 hours
“had an episode nursing interventions, and family. nursing interventions,
of sudden-onset Impaired verbal the client will be able Rationale: to promote cooperation the goal was met. the
numbness and communication to: -Learn patient needs and pay patient was able to:
tingling in the related to attention to nonverbal cues
right limb, with neuromuscular -Indicate an Rationale: The nurse should set -Indicated an
slight confusion impairment as understanding of the aside enough time to attend to all understanding of the
and slurred evidenced by communication of the details of patient care. Care communication
speech, 3 days slurred speech problems measures may take longer to problems
previously.” as -Establish method of complete in the presence of a -Established method of
reported by her communication in communication deficit. communication in which
daughter which needs can be -Talk directly to the patient, needs can be
expressed speaking slowly and distinctly. expressed
Objective: -Use resources Phrase questions to be answered -Used resources
-Confused appropriately simply by yes or no. appropriately
-Loss of -Verbalization of Rationale: Reduces confusion and -Verbalized the
consciousness understanding the allays anxiety at having to process understanding of
therapy need and respond to large amounts of therapy needed
information at one time.
-Discuss the importance of patient
to consult speech therapist
Rationale: Assesses individual
verbal capabilities and sensory,
motor, and cognitive functioning to
identify deficits/therapy needs.

Reference:https://nurseslabs.com/impaired-verbal-communication/
https://nurseslabs.com/8-cerebrovascular-accident-stroke-nursing-care-plans/3/

12. How do you monitor patient’s level of consciousness and compare with the NIHSS. LADJAMATLI

● The tool we use to assess the level of consciousness is the Glasgow Coma Scale (GCS). This tool is used at the bedside in
conjunction with other clinical observations and it allows us to have a baseline and ongoing measurement of the level of
consciousness (LOC) for our patients.
● The NIH Stroke Scale is a widely used tool that was built to assess the cognitive effects of a stroke. In more scientific terms, it
“provides a quantitative measure of stroke-related neurologic deficit” (NIH Stroke Scale).

Although the NIHSS was first developed as a clinical tool for research on stroke patients, it is now used by health
professionals to determine the severity of a stroke. It also helps create a common language between all people involved in a
stroke patient’s treatment. In a treatment setting, the scale has three major purposes:

○ It evaluates the severity of the stroke

○ It helps determine the appropriate treatment
○ It predicts patient outcomes.
● it focuses on the following 6 major areas of the neurologic examination:
○ Level of consciousness
○ Visual function
○ Motor function
○ Sensation and neglect
○ Cerebellar function
○ Language
13. Identify what important health teachings to be included while the patient is confine in the rehabilitation unit?
=1. ` Rehabilitation will focus on an exercise program consisting of (gentle exercise only)

· Motor-skill exercises. These exercises can help improve muscle strength and coordination. You might have
therapy to strengthen your swallowing.

· Mobility training-use of aids, such as a walker, canes, wheelchair or ankle brace. The ankle brace can
stabilize and strengthen your ankle to help support your body's weight while you relearn to walk.

· Range-of-motion therapy- Certain exercises and treatments can ease muscle tension (spasticity) and help
you regain range of motion.

2. ways to reduce the chances of another stroke

· Proper diet- Fruits, vegetables, lean proteins, whole grains, and healthy plant oils (like olive oil) (avoid amount of
saturated fat, fried foods, and sugar)
· Gently exercise (walking is the most recommended)
3. cognitive and emotional activity such as:
· Therapy for communication disorders- Speech therapy can help you regain lost abilities in speaking, listening,
writing and comprehension.
4. We can also included safety measure or fall precaution such as:
· Proper use of cane
· Put in handrails and other safety devices ( handle bars)

14. Design a discharge teaching plan for Patient B with emphasis on (MODEL) Medications, Out-patient Follow up visit, Diet, Exercises,
Lifestyle modifications.
NAPII & RODRIGO

Assign your student to make nurses notes utilizing SOAPIE & ADPIE charting. SARABIA
TIME/ DATE/ SHIFT NURSE’S NOTES

9/2/21 ——————-------------------————Emergency Room Notes—-------------------------——————

Admitted female 70 years old; white shirt, red pants; weight 131 lbs and height 5’6; accompanied by
daughter; awake, confused - - - ------------------------------------------------------------------- - - Alliah Ruiz, RN
10:25 AM A- experiencing slight shortness of breath, and confusion, V/S: BP- 150/95 mmHg, RR- 16 bpm, HR- 98
10:30 AM bpm--------------------------------------------------
D- Impaired Physical Mobility related to hemiplegia
P- At the end of 8 hours nursing care, maintain normal vital signs as evidenced by BP, RR and HR within
10:35 AM normal limits and peripheral pulses strong and equal, with adequate capillary refill time. ------------------------
I- Assisted in transfer to stretcher; ----------------------------------------------------------------------------------
10:40 AM - Referred to ER physician; Physical examination done, has pain in her left arm, a slight headache,
slight carotid bruits on the right; NIHSS was done and results showed left hemiparesis and left
visual/spatial neglect.
12:10 PM - All consent forms have been read and signed; Requested the following laboratory exams: CBC,
Prothrombin time, serum electrolytes levels, cardiac biomarkers,, and renal function studies; CT
Scan and Cerebral Angiography.
- Relayed results to the referred consultant neurologist specialist by the ER primary physician as
laboratory examination results were shown.
- As per doctor’s order, Started IV fluid of NSS at the left arm regulated at 30 gtts and intravenous rt-
12:15 PM PA (thrombolytic therapy) at a dose of 0.9 mg/kg and attached to infusion pump; Antiplatelet
therapy will start at an initial dose of Aspirin 325 mg, 24 hours after thrombolytic therapy, and a
12:20 PM maintenance dose of 75 mg per day.
- Advised for admission to Neurologic Unit; Informed Neuro unit out admission of patient
- Assessed physical condition; Explained the transfer to patient and S/O to Neuro Unit; Maintained
physical well-being during transport (side rails up); Assisted in arrival to Neuro unit;
- Announced arrival to the new unit; Transported to a new room and assisted in transfer to bed;
Provided verbal report about the condition to the receiving unit nurse.
E- Goal not met. showed no improvement as evidenced by V/S: BP- 150/95 mmHg, RR- 16 bpm, HR- 98
bpm : Complete blood count, Prothrombin time, serum electrolyte levels, cardiac biomarkers, and renal
12:30 PM function studies are within normal limits; CT scan of the brain indicates a thrombus in a branch of the right
internal carotid artery, with approximately 50% occlusion due to atherosclerosis; Area of infarction in the
right anterior hemisphere and there is no evidence of a subarachnoid hemorrhage; Endorsed to Neuro-
medical unit; Handover of nurses notes- - - - - - - A.R. RN
------------------------------------- ------------------------------------------------
 --------------------------------------------- Neuro-Medical Ward Notes -------------------------------------------------------

Received in stretcher, awake; with IV rt-PA @0.9 mg/k.---------------------------------------Ruhaina Jawad, RN

12: 30 PM
A: V/S as follows: BP- 148/92 mmHg, RR- 16 bpm, HR- 94 bpm; T- 37.2°C; NIHSS result to left
hemiparesis and left visual/spatial neglect; CT scan of the brain indicates a thrombus in a branch of the
12:35 PM right internal carotid artery, with approximately 50% occlusion due to atherosclerosis; Area of infarction in
the right anterior hemisphere---------------------------------------------------------

D: Impaired Physical Mobility related to hemiplegia

12:45 PM
P: Continue to maintain normal vital signs as evidenced by BP, RR and HR within normal limits and
peripheral pulses strong and equal, with adequate capillary refill time. ------------------------AR.RN
1:00 PM I : V/S as follows: BP- 148/92 mmHg, RR- 16 bpm, HR- 94 bpm; T- 37.2°C; NIHSS result to left
hemiparesis and left visual/spatial neglect; CT scan of the brain indicates a thrombus in a branch of the
1:45 PM right internal carotid artery, with approximately 50% occlusion due to atherosclerosis; Area of infarction in
the right anterior hemisphere.
- Transferred to bed comfortably; Changed to hospital gown; V/S rechecked: 140/90 mmHg, RR- 16
bpm, HR- 90 bpm; T- 37.2°C; Monitored and recorded IV rt-PA.
- Observed affected side for color, edema, or other signs of compromised circulation.
- Inspected skin regularly, particularly over bony prominences; Gently massaged any reddened
2:45 PM areas and provided aids such as sheepskin pads as necessary.
- Placed pillow under axilla to abduct arm to prevent adduction of shoulder and flexion of elbow;
Elevated arm and hand to promote venous return and help prevent edema formation; Placed knee
and hop in extended position to maintain functional position.
- Changed positions every 2 hr (supine/side lying), more often if placed on the affected side.
3:00 PM ———————
E: Goal partially met V/S taken as follows: 140/90 mmHg, RR- 15 bpm, HR- 88 bpm; T- 37.2°C; no edema
formation and other signs of compromised circulation; no signs of adduction of shoulder and flexion of
elbow; maintained in functional position; endorsed to next NOD.
—————————————————————————A.R, RN
 -------------------------------------------------Medical Ward Notes- 3-11 PM-----------------------------------------------
3:00 PM Received patient in a ward room, awake; with IV rt-PA @ 0.9 mg/kg; and with a hospital gown, Almena
Ladjamatli, R.N------------------------------------------------------------------------------

3:15 PM A: /S taken as follows: 140/90 mmHg, RR- 15 bpm, HR- 88 bpm; T- 37.2°C; no edema formation and
other signs of compromised circulation; no signs of adduction of shoulder and flexion of elbow; maintained
in functional position
D: Impaired Physical Mobility related to hemiplegia
P: Maintain normal vital signs as evidenced by BP, RR and HR within normal limits and peripheral pulses
strong and equal, with adequate capillary refill time-------------------------------------------------------------A.L.RN
3:35 PM I: V/S rechecked: 140/90 mmHg, RR- 17 bpm, HR- 90 bpm; T- 37.0°C;--------------------------------------------
- Monitored and recorded IV rt-PA.---------------------------------------------------
- Maintained leg in neutral position with a trochanter roll to prevents external hip rotation; Place
hard hand-rolls in the palm with fingers and thumb opposed to decrease the stimulation of finger
4:00 PM flexion, maintaining finger and thumb in a functional position.------------------------------
- Inspected skin regularly, particularly over bony prominences; Gently massaged any reddened
5:00 PM areas and provided aids such as sheepskin pads as necessary---------------------
- As doctor order; Additional medication of Atorvastatin 20 mg 1 tab and insert catheter; Gently
5:05 PM insert the catheter into the urethra opening until urine begins to flow out.------------------
- Administered medication of Atorvastatin 20 mg 1 tab--------------------------------------------------
5:20 PM - Assessed the patient with the NIHSS; Assess extent of impairment initially and on a regular basis.
Classify according to 0–4 scale; Evaluate the patient's risk for
5:45 PM complications------------------------------------------------------------------------
- Assessed the patient with the Berg Balance Scale; Instruct the client to Lift her arm to 90 degrees
and stretch out her fingers and reach forward as far as she can. (Place a ruler at the end of
fingertips when the arm is at 90 degrees. Fingers should not touch the ruler while reaching
6:00 PM forward.);--------------------------------------------------
- Assisted the patient while taking the Stops Walking When Talking test;
--------------------------------------------------------
6:45 PM - Assisted patient to develop sitting balance by raising head of bed, assist to sit on edge of bed,
having patient to use the strong arm to support body weight and move using the strong leg. Assist
7:30 PM to develop standing balance by putting flat walking shoes, support patient’s lower back with hands
while positioning own knees outside patient’s knees, assist in using parallel
bars;--------------------------------------------------------------------
‣ Changed positions every 2 hr (supine/side lying), more often if placed on the affected
 side.--------------------------------------------------------------------------------
8:00 PM ‣ V/S rechecked: 140/90 mmHg, RR- 15 bpm, HR- 89 bpm; T- 37.2°C;
E: Goal met. V/S rechecked: 140/90 mmHg, RR- 17 bpm, HR- 90 bpm; T- 37.0°C; NIHSS-12; cognitive
and communication skills are intact; Berg Balance Scale-43; Patient does stop walking to engage in
conversation; (CES-D) Scale-no sign of depression; no signs of external hip rotation; no signs of
increased stimulation of finger flexion and other signs of functional position; endorsed to next
11:00 PM NOD------------------------------------------------------------A.L.RN

--------------------------------------------------- Medical Ward Notes11-7am -------------------------------------------------

11:00 PM
Received in a ward room, awake; lying in a supine position;with IV rt-PA @ 0.9 mg/kg; and with a hospital
gown. --------------------------------------------------------------------------------------------------- Saima Taradji, RN
11:35 PM
A: V/S as follow:140/90 mmHg, RR- 17 bpm, HR- 90 bpm; T- 37.0°C; NIHSS-12; cognitive and
communication skills are intact; Berg Balance Scale-43; Patient does stop walking to engage in
conversation; (CES-D) Scale-no sign of depression; no signs of external hip rotation; no signs of
12:30 AM increased stimulation of finger flexion and other signs of functional position

D: Impaired Physical Mobility related to hemiplegia

1:00 AM
P- Maintain normal vital signs as evidenced by BP, RR and HR within normal limits and peripheral pulses
strong and equal, with adequate capillary refill time---------------------------------------------------------------------

1:35 AM I: V/S rechecked: 135/90mmHg, RR-19 bpm, HR-90 bpm, T-37.0°C; NIHSS-12; cognitive and
communication skills are intact; Berg Balance Scale-43;(CES-D) Scale-no sign of depression are present.

2:45 AM - Referral to stroke rehabilitation team; collaborate with the rehabilitation team to assess the patient
rehabilitative needs;---------------------------------------------------------------
3: 55 AM - Assessed the patient with the NIHSS; Assess extent of impairment initially and on a regular basis.
Classify according to 0–4 scale; Assess the patient with the Berg Balance Scale; Instruct the
patient to Lift her arm to 90 degrees and stretch out her fingers and reach forward as far as she
can. (Place a ruler at the end of fingertips when the arm is at 90 degrees. Fingers should not
 touch the ruler while reaching forward).-----------------
- Collaborate with the rehabilitation team to develop and assist the patient in using assistive
devices to achieve activities of daily living as independently as possible.---------------
- Assist patients with exercise and perform ROM exercises for both the affected and unaffected
4:35 AM sides; Encourage the patient to touch the paralyzed side and to participate in passive ROM
exercises as appropriate.------------------------------------------------------------Assist the patient while
taking the Stops Walking When Talking test; Encouraged the patient to develop sitting balance by
raising head of bed, assist to sit on edge of bed, having patient use the strong arm to support
body weight and move using the strong leg. Assist to develop standing balance by putting flat
5:55 AM walking shoes, support patient’s lower back with hands while positioning own knees outside
patient’s knees, assist in using parallel bars;---------------------------------------------------------------
- Change positions at least every 2 hr. (supine, side lying) and possibly more often if placed on the
6: 30 AM affected side.------------------------------------------------------------------
- Teach the patient how to use a walker, cane, or wheelchair as appropriate; Discuss the
necessary home adaptation to the patient family such as wheelchair ramp, shower seat,
bathroom modifications.-------------------------------------------------------
- Ensure the correct positioning of the patient to prevent contractures, prevent hip reduction by
positioning the patient on his side with his hips slightly flexed and in as natural position as
possible; use prone position if possible; and prevent shoulder adduction by placing pillow in the
7:00 AM axilla.-----------------------------------------------------------------
- Discussed the program with Patient Families and explained the course of rehabilitation and the
expectations; Rehabilitation will focus on an exercise program consisting of aerobic exercise,
such as walking, and coordination and balance activities.---------------
- Coordinate with the rehabilitation team to provide discharge instructions for patients to continue at
home and recommend some activity as a secondary preventive’s measures

E: Goal met. V/S rechecked: 130/90mmHg, RR-16 bpm, HR-89bpm, T-37.0°C; NIHSS-5; cognitive and
communication skills are intact; Berg Balance Scale-56;(CES-D) Scale- no sign of depression; no signs
of external hip rotation; no signs of increased stimulation of finger flexion and other signs of functional
positions.-----------------------------------------------------------ST, RN
TIME/ DATE/ SHIFT NURSE’S NOTES
 9/2/21 ——————————Emergency Room Notes———————
Admitted female 70 years old; white shirt, red pants; weight 131 lbs and height 5’6; accompanied by
daughter; awake, confused - - - ---------------------------------------------------------------------- - - - - AR, RN
10:25 AM S-“ Medyo nahihirapan po akong huminga”.-------------------------------------------------------------------AR,RN
10:30 AM O-.V/S: BP- 150/95 mmHg, RR- 16 bpm, HR- 98 bpm---------------------------------------------------------AR,RN
A- experiencing slight shortness of breath, and confusion-----------------------------------------------------------
P- At the end of 8 hours nursing care, maintain normal vital signs as evidenced by BP, RR and HR within
10:35 AM normal limits and peripheral pulses strong and equal, with adequate capillary refill time. ------------------------
I- Assisted in transfer to stretcher; ----------------------------------------------------------------------------------
10:40 AM - Referred to ER physician; Physical examination done, has pain in her left arm, a slight headache,
slight carotid bruits on the right; NIHSS was done and results showed left hemiparesis and left
visual/spatial neglect.
12:10 PM - All consent forms have been read and signed; Requested the following laboratory exams: CBC,
Prothrombin time, serum electrolytes levels, cardiac biomarkers,, and renal function studies; CT
Scan and Cerebral Angiography.
- Relayed results to the referred consultant neurologist specialist by the ER primary physician as
laboratory examination results were shown.
- As per doctor’s order, Started IV fluid of NSS at the left arm regulated at 30 gtts and intravenous rt-
12:15 PM PA (thrombolytic therapy) at a dose of 0.9 mg/kg and attached to infusion pump; Antiplatelet
therapy will start at an initial dose of Aspirin 325 mg, 24 hours after thrombolytic therapy, and a
12:20 PM maintenance dose of 75 mg per day.
- Advised for admission to Neurologic Unit; Informed Neuro unit out admission of patient
- Assessed physical condition; Explained the transfer to patient and S/O to Neuro Unit; Maintained
physical well-being during transport (side rails up); Assisted in arrival to Neuro unit;
- Announced arrival to the new unit; Transported to a new room and assisted in transfer to bed;
Provided verbal report about the condition to the receiving unit nurse.
E- Goal not met. showed no improvement as evidenced by V/S: BP- 150/95 mmHg, RR- 16 bpm, HR- 98
bpm : Complete blood count, Prothrombin time, serum electrolyte levels, cardiac biomarkers, and renal
12:30 PM function studies are within normal limits; CT scan of the brain indicates a thrombus in a branch of the right
internal carotid artery, with approximately 50% occlusion due to atherosclerosis; Area of infarction in the
right anterior hemisphere and there is no evidence of a subarachnoid hemorrhage; Endorsed to Neuro-
medical unit; Handover of nurses notes- - - - - - - A.R. RN
------------------------------------- ------------------------------------------------

------------------------------------------------ Neuro-Medical Ward Notes -------------------------------------------------

 S/O: Received in stretcher, awake; with IV rt-PA @0.9 mg/kg, V/S as follows: BP- 148/92 mmHg, RR- 16
bpm, HR- 94 bpm; T- 37.2°C; NIHSS result to left hemiparesis and left visual/spatial neglect; CT scan of
12: 30 PM the brain indicates a thrombus in a branch of the right internal carotid artery, with approximately 50%
occlusion due to atherosclerosis; Area of infarction in the right anterior
hemisphere.----------------------------------Ruhaina Jawad, RN
12:35 PM A: Impaired Physical Mobility related to hemiplegia

P: Continue to maintain normal vital signs as evidenced by BP, RR and HR within normal limits and
peripheral pulses strong and equal, with adequate capillary refill time. ------------------------AR.RN
12:45 PM I : V/S as follows: BP- 148/92 mmHg, RR- 16 bpm, HR- 94 bpm; T- 37.2°C; NIHSS result to left
hemiparesis and left visual/spatial neglect; CT scan of the brain indicates a thrombus in a branch of the
right internal carotid artery, with approximately 50% occlusion due to atherosclerosis; Area of infarction in
1:00 PM the right anterior hemisphere.
- Transferred to bed comfortably; Changed to hospital gown; V/S rechecked: 140/90 mmHg, RR- 16
1:45 PM bpm, HR- 90 bpm; T- 37.2°C; Monitored and recorded IV rt-PA.
- Observed affected side for color, edema, or other signs of compromised circulation.
- Inspected skin regularly, particularly over bony prominences; Gently massaged any reddened
areas and provided aids such as sheepskin pads as necessary.
- Placed pillow under axilla to abduct arm to prevent adduction of shoulder and flexion of elbow;
Elevated arm and hand to promote venous return and help prevent edema formation; Placed knee
2:45 PM and hop in extended position to maintain functional position.
- Changed positions every 2 hr (supine/side lying), more often if placed on the affected side.
———————
E: Goal partially met V/S taken as follows: 140/90 mmHg, RR- 15 bpm, HR- 88 bpm; T- 37.2°C; no edema
formation and other signs of compromised circulation; no signs of adduction of shoulder and flexion of
3:00 PM elbow; maintained in functional position; endorsed to next NOD.
—————————————————————————A.R, RN

-------------------------------------------------Medical Ward Notes- 3-11 PM-----------------------------------------------

S/O: Received patient in a ward room, awake; with IV rt-PA @ 0.9 mg/kg; and with a hospital gown, V/S
taken as follows: 140/90 mmHg, RR- 15 bpm, HR- 88 bpm; T- 37.2°C; no edema formation and other
signs of compromised circulation; no signs of adduction of shoulder and flexion of elbow; maintained in
functional position; ----------------------------------A.L, RN
A: Impaired Physical Mobility related to hemiplegia
P: Maintain normal vital signs as evidenced by BP, RR and HR within normal limits and peripheral pulses
strong and equal, with adequate capillary refill time---------------------------------------------------------------------
3:00 PM A.L.RN
I: V/S rechecked: 140/90 mmHg, RR- 17 bpm, HR- 90 bpm; T- 37.0°C; Monitored and recorded IV rt-
PA.---------------------------------
3:15 PM - Maintained leg in neutral position with a trochanter roll to prevents external hip rotation; Place
hard hand-rolls in the palm with fingers and thumb opposed to decrease the stimulation of finger
flexion, maintaining finger and thumb in a functional position.-----------
- Inspected skin regularly, particularly over bony prominences; Gently massaged any reddened
areas and provided aids such as sheepskin pads as necessary---------------------
- As doctor order; Additional medication of Atorvastatin 20 mg 1 tab and insert catheter; Gently
3:35 PM insert the catheter into the urethra opening until urine begins to flow out.-------------
- Administered medication of Atorvastatin 20 mg 1 tab--------------------------------------------------
- Assessed the patient with the NIHSS; Assess extent of impairment initially and on a regular basis.
Classify according to 0–4 scale; Evaluate the patient's risk for
4:00 PM complications------------------------------------------------------------------------
- Assessed the patient with the Berg Balance Scale; Instruct the client to Lift her arm to 90 degrees
5:00 PM and stretch out her fingers and reach forward as far as she can. (Place a ruler at the end of
fingertips when the arm is at 90 degrees. Fingers should not touch the ruler while reaching
5:05 PM forward.);--------------------------------------------------
- Assisted the patient while taking the Stops Walking When Talking test;
5:20 PM --------------------------------------------------------
- Assisted patient to develop sitting balance by raising head of bed, assist to sit on edge of bed,
5:45 PM having patient to use the strong arm to support body weight and move using the strong leg. Assist
to develop standing balance by putting flat walking shoes, support patient’s lower back with hands
while positioning own knees outside patient’s knees, assist in using parallel
bars;--------------------------------------------------------------------
6:00 PM ‣ Changed positions every 2 hr (supine/side lying), more often if placed on the affected
side.--------------------------------------------------------------------------------
‣ V/S rechecked: 140/90 mmHg, RR- 15 bpm, HR- 89 bpm; T- 37.2°C;
6:45 PM E: Goal met. V/S rechecked: 140/90 mmHg, RR- 17 bpm, HR- 90 bpm; T- 37.0°C; NIHSS-12; cognitive
and communication skills are intact; Berg Balance Scale-43; Patient does stop walking to engage in
7:30 PM conversation; (CES-D) Scale-no sign of depression; no signs of external hip rotation; no signs of
increased stimulation of finger flexion and other signs of functional position; endorsed to next
NOD------------------------------------------------------------A.L.RN

8:00 PM
 --------------------------------------------------- Medical Ward Notes11-7am -------------------------------------------------

11:00 PM S/O: Received in a ward room, awake; lying in a supine position;with IV rt-PA @ 0.9 mg/kg; and with a
hospital gown. V/S as follow:140/90 mmHg, RR- 17 bpm, HR- 90 bpm; T- 37.0°C; NIHSS-12; cognitive
and communication skills are intact; Berg Balance Scale-43; Patient does stop walking to engage in
conversation; (CES-D) Scale-no sign of depression; no signs of external hip rotation; no signs of
increased stimulation of finger flexion and other signs of functional
position--------------------------------------------- Saima Taradji, RN

11:00 PM A:Impaired Physical Mobility related to hemiplegia

P- Maintain normal vital signs as evidenced by BP, RR and HR within normal limits and peripheral pulses
11:35 PM strong and equal, with adequate capillary refill time---------------------------------------------------------------------

I: V/S rechecked: 135/90mmHg, RR-19 bpm, HR-90 bpm, T-37.0°C; NIHSS-12; cognitive and
communication skills are intact; Berg Balance Scale-43;(CES-D) Scale-no sign of depression are present.
12:30 AM
- Referral to stroke rehabilitation team; collaborate with the rehabilitation team to assess the patient
rehabilitative needs;---------------------------------------------------------------
1:00 AM - Assessed the patient with the NIHSS; Assess extent of impairment initially and on a regular basis.
Classify according to 0–4 scale; Assess the patient with the Berg Balance Scale; Instruct the
patient to Lift her arm to 90 degrees and stretch out her fingers and reach forward as far as she
can. (Place a ruler at the end of fingertips when the arm is at 90 degrees. Fingers should not
1:35 AM touch the ruler while reaching forward).-----------------
- Collaborate with the rehabilitation team to develop and assist the patient in using assistive
devices to achieve activities of daily living as independently as possible.---------------
2:45 AM - Assist patients with exercise and perform ROM exercises for both the affected and unaffected
sides; Encourage the patient to touch the paralyzed side and to participate in passive ROM
3: 55 AM exercises as appropriate.------------------------------------------------------------Assist the patient while
taking the Stops Walking When Talking test; Encouraged the patient to develop sitting balance by
raising head of bed, assist to sit on edge of bed, having patient use the strong arm to support
body weight and move using the strong leg. Assist to develop standing balance by putting flat
walking shoes, support patient’s lower back with hands while positioning own knees outside
patient’s knees, assist in using parallel bars;---------------------------------------------------------------
 - Change positions at least every 2 hr. (supine, side lying) and possibly more often if placed on the
affected side.------------------------------------------------------------------
4:35 AM - Teach the patient how to use a walker, cane, or wheelchair as appropriate; Discuss the
necessary home adaptation to the patient family such as wheelchair ramp, shower seat,
bathroom modifications.-------------------------------------------------------
- Ensure the correct positioning of the patient to prevent contractures, prevent hip reduction by
positioning the patient on his side with his hips slightly flexed and in as natural position as
5:55 AM possible; use prone position if possible; and prevent shoulder adduction by placing pillow in the
axilla.-----------------------------------------------------------------
- Discussed the program with Patient Families and explained the course of rehabilitation and the
6: 30 AM expectations; Rehabilitation will focus on an exercise program consisting of aerobic exercise,
such as walking, and coordination and balance activities.---------------
- Coordinate with the rehabilitation team to provide discharge instructions for patients to continue at
home and recommend some activity as a secondary preventive’s measures

E: Goal met. V/S rechecked: 130/90mmHg, RR-16 bpm, HR-89bpm, T-37.0°C; NIHSS-5; cognitive and
communication skills are intact; Berg Balance Scale-56;(CES-D) Scale- no sign of depression; no signs
7:00 AM of external hip rotation; no signs of increased stimulation of finger flexion and other signs of functional
positions.-----------------------------------------------------------ST, RN