Case for Study: Cerebrovascular Accident

1. Patient RAM, 47 yrs. Old, male , married technician from Nursery, Masbate City was rushed to
ER of MPH on Nov. 15 , 2021 due to slurring of speech, left-sided weakness and numbness.
Negative chest pain, LOC (stuporous). Vital signs taken are as follows: BP-180/110, HR- 84bpm,
RR- 18cpm, T- 36.5dc, sPa02 -94%. GCS -Was seen and examined by Dr. ARA and subsequently
admitted at 3:00pm with a diagnosis of Cerebrovascular Accident(R) with the following doctor’s
orders:
11/15/2021 3:00pm Admit to Medical Ward Bed #1
Secure consent to care
CBR-NBP
NPO
Insert NGT for feeding
May give Ensure 6 scoops in 100ml sterilized water/NGT Q 4 hours
02 supplementation @ 5LPM via face mask
IVF: PNSS 1L to KVO
Medications:
Nicardipine drip 1amp(10mg) + 90cc D5W to IVF as piggyback in Soluset infuse @
10-11ugtts/min titrate( increase and decrease by 5) till BP is maintained at 140-150/60-70
mmHg
Citicoline 1gm IVT q 8 hours
Mannitol 100cc SIVI over 30 minutes q 6 hours
Furosemide 40mg/ amp 1 amp IVT now
Dexamethasone 8mg/amp 1 amp IVT q 8 hours
MVT+AA 20ml/amp 1 amp IVP q 24 hours
Losartan 80mg/tab 1 tab per NGT q 24 hours
Aspirin 80mg/tab 2 tabs per NGT now then 1 tab/NGT q 24 hours thereafter
Simvastatin 10mg/tab 1tab per NGT q 24 hours, hs
Labs:
For CBG (STAT)
For 12 leads ECG(STAT)
CBC, UA
For serum Electrolytes
For FBS, Lipid Profile
For BUN ,sCREA
For Chest X-ray(AP-LAT)
For sPa02 monitoring q shift and record
Insert indwelling catheter aseptically and attach to urine bag
Monitor VS q hour and record
Monitor GCS q hour and record
Monitor UO q 4 hours and record
For I and O q shift and record
Refer accordingly.
Signed :
Dr. ARA
You as the incoming Nurse on duty for the 3-11 shift will receive this patient from the outgoing
nurse.
1. After careful analysis and interpretation of the doctor’s orders, outline the steps that you
will follow to carry out the order after your endorsement. It is assumed that you are already
done with your patient to patient endorsement and checking of the emergency meds and
the whole medical unit and it was endorsed to you that the last BP taken was
180/100mmHg.
- IVF: PNSS 1L to KVO
- Insert NGT for feeding
-02 supplementation @ 5LPM via face mask
- May give Ensure 6 scoops in 100ml sterilized water/NGT Q 4 hours
Administered:
*Furosemide 40mg/ amp 1 amp IVT now
*Nicardipine drip 1amp(10mg) + 90cc D5W to IVF as piggyback in Soluset infuse @ 10-
11ugtts/min titrate( increase and decrease by 5) till BP is maintained at 140-150/60-70 mmHg
- Request for laboratory
- Insert indwelling catheter aseptically and attach to urine bag
-Monitor VS q hour and record
-Monitor GCS q hour and record

2. Base on your assessment findings, what is the GCS score of your patient?

-for eye response

Spontaneous - Open before stimulus(+4)

-For verbal reponse

Inappropriate words 3 points

-For motor response

Withdraws in response to pain 4 points

=Total score of the patient is 11

3. In preparing the medications, how are you going to pile up the sequence of the cards or
medicine tickets.
- Pile up the medicine tickets according to its due

Furosemide 40mg/ amp 1 amp IVT now

Mannitol 100cc SIVI over 30 minutes q 6 hours

Nicardipine drip 1amp(10mg) + 90cc D5W to IVF as piggyback in Soluset infuse @ 10-
11ugtts/min titrate( increase and decrease by 5) till BP is maintained at 140-150/60-70 mmHg
Citicoline 1gm IVT q 8 hours
Dexamethasone 8mg/amp 1 amp IVT q 8 hours
MVT+AA 20ml/amp 1 amp IVP q 24 hours
Losartan 80mg/tab 1 tab per NGT q 24 hours
Aspirin 80mg/tab 2 tabs per NGT now then 1 tab/NGT q 24 hours thereafter
Simvastatin 10mg/tab 1tab per NGT q 24 hours, hs

4. How many medications are due to be given within your shift?

-11ugtts/min titrate( increase and decrease by 5) till BP is maintained at 140-150/60-70 mmHg
-Citicoline 1gm IVT q 8 hours
-Mannitol 100cc SIVI over 30 minutes q 6 hours
-Furosemide 40mg/ amp 1 amp IVT now

- Dexamethasone 8mg/amp 1 amp IVT q 8 hours

5. In preparing for the lab requests which lab request should be given priority? And why?
- For 12 leads ECG(STAT), the patients Blood pressure is high. You should probably have an
ECG if you have risk factors for an enlarged heart such as high blood pressure or symptoms
of heart disease, such as chest pain, shortness of breath, an irregular heartbeat or heavy
heartbeats

6. You are going to catheterize the patient.If a catheter is to remain in place for continuous
drainage and for monitoring I and O, What type of catheter is to be used and what are you
going to do so that it will not slip off and to keep the catheter in place?What are the supplies
and materials that you need to prepare for this procedure?
- Foley catheter
- Check the position of your catheter and drainage bag. Ensure the bag is positioned below
your bladder when you are lying, sitting or standing. Use a water-filled syringe to inflate
the balloon via sterile tubing connected to the catheter. The inflated balloon serves as an
anchor so as not to displace the catheter when moving
- Foley catheter, Sterile Gloves, medical-grade disinfectant, cotton swabs, surgical drapes,
lubricant, water, tubing, a drainage bag, and tape. 

7. After one hour, you checked the mental status of your patient and you found out that the
patient no longer spontaneously opens his eyes.Evaluate now the GCS of your patient and
what are you going to do,what is your action?
Eye opening response
To pain only (not applied to face) 2 points
Verbal response
No response 1 point
Motor response
Flexion in response to pain (decorticate posturing) 3 points
6 points
First and foremost is to call the doctor.
 8. After 4 hours, you checked the BP and it falls down to 130/70mmHg, what will be your next
move.
- Stop administering Nicardipine drip 1amp(10mg) + 90cc D5W to IVF as piggyback in
Soluset infuse @ 10-11ugtts/min titrate

9. One hour before the end of your shift, you go to the patient’s bedside to check the urine
output and you noticed that only around 20ml is seen on the urine bag, what are you going
to do.
- Low urine output also occurs when there is a decreased blood supply to the kidney, such
as occurs with dehydration or Obstruction of outflow of the urine the first thing do is to
check the catheter if it is in he right position. Continue IV fluid for possible dehydration.

10. Identify your focus and formulate your nursing diagnosis based on NANDA(maybe more
than one),and document using the FDAR format.
GOOD LUCK…

Date/time Focus Progress note (DAR)

Nov. 15 , 2021 Decreased Patient RAM, 47 yrs. Old, male , married technician from Nursery,
3:00 pm cardiac Masbate City was rushed to ER of MPH on Nov. 15 , 2021 due to:
output
related to
increased
peripheral
vascular
resistance
as evidence
by BP
1180/110
D- Slurring of speech, left-sided weakness and numbness.
Negative chest pain, LOC (stuporous).
Vital signs taken are as follows: BP-180/110, HR- 84bpm, RR- 18cpm, T-
36.5dc, sPa02 -94%.

A- Secure consent to care

CBR-NBP
NPO
Insert NGT for feeding
May give Ensure 6 scoops in 100ml sterilized water/NGT Q 4
hours
02 supplementation @ 5LPM via face mask
IVF: PNSS 1L to KVO
Administer Medications:
Request Laboratory
For sPa02 monitoring q shift and record
Insert indwelling catheter aseptically and attach to urine bag
 Monitor VS q hour and record
Monitor GCS q hour and record
Monitor UO q 4 hours and record
For I and O q shift and record
Refer accordingly.

Nov. 17, 2021 - Patients blood preassure will decrease, the GCS scale will be
7:00 pm back in normal parameters.