Case Study 1

Endorsement to ER: “I am signing out Adobo Gisado Paminta,62 yo male, Birthday, Dec 25,
1960, with weight of 75kg. with known hypertension and atrial fibrillation who is not on
anticoagulation”. “He was found down on the floor at 7:10 am by his wife. He was last seen
normal at 10 pm last night. He is aphasic with right-sided weakness, GCS of 11, HR of
130/minute and BP of 200/110 mmHg. IV Metoprolol 5 mg given and his follow up HR was
94/minute and BP was 182/90 mmHg” ER to ICU: “Upon arrival to the ER at 9:10 am his
NIHSS was 21 - global aphasia, left gaze preference, right hemiplegia and neglect.” “CT
completed at 9:26 am showed a left dense MCA sign. CTA showed a left M1 occlusion. CTP
showed a core of 38 ml, penumbra of 140 ml, mismatch volume 102 ml, mismatch ratio 3.7.”
“He was out of the IV tPA window. Endovascular team was notified at 9:38 am” . “He was
taken to the cath lab at 9:50 am. His HR was 106/minute and BP was 190/106 mmHg. Groin
puncture was attained at 10:06 am. TICI3 revascularization was achieved. He had started
moving his right arm and leg few minutes after the procedure”. “His target post procedural BP
should be <140/80mmHg”. MRI brain is pending.

Patient’ Name: Date of Birth: Age: Sex: Room No.:

Adobo Gisado Paminta Dec 25, 1960 62 y/o M

Last Name First Name Middle Name MM DD YY Weight:

Pamino Adobo Gisado 12 25 1960 75 kg

Time last seen before current symptoms started Day: Time: 9:10am
7:00am

Objective: Confirm diagnosis of stroke and perform initial physical evaluation in less than 10 minutes

Symptom onset <4 hours ago Symptom onset >4 hours ago Time of onset unknown
7:10AM
He is aphasic with right sided  No anticoagulant use
weakness  Global aphasia 9:10AM
GCS of 11  Left gaze preference  Patient's NIHSS was 21
HR of 130 minute  Right Hemiplegia  Global aphasia
BP of 200/110 mmHg  Neglect  left gaze preference
 Left dense MCA sign  right hemiplegia and neglect

9:50pm
HR was 106/minute
BP was 190/106 mmHa
Patient history and physical examination:
Not on an anti-coagulation -GCS 11
NIHSS was 21 - global aphasia, left gaze preference, right hemiplegia and neglect
Hypertension and atrial fibrillation
Initial Vital Signs:
BP• 200/110 mmHg
HR: 130/mins
Given Metoprolol Vital Signs:
BP• 182/90 mmHg
HR: 94/mins
Vital Signs:
BP:200/110 mmHg
190/106 mmHg
HR 106 mins

NIHSS score 21

Absolute contraindications for rt-PA NO tPA unless BP is reduced

Significant lab results/ Diagnostics CT Scan

Current medication (if any)

IV Metoprolol 5mg

Category (Mild/Mod/High Risk): Moderate

Pending Diagnostics MRI

Basing on the weigh, if to give tPA, what computation

should be the dose to give to the patient? Total dose= 0.9mg x 75kg= 67.5mg
(give the computation)
The total dose of Pa needed is= 67.5mg
Computation:
Bolus= 10% of total dose
67 5 × 0.10 mg= 6.75 rounded off it will
Equivalent to 6 8
• Administer 6.75/6.8 mg (10%) in a 1 min
bolus
Computation:
Infusion Dose= 90% of total dose 67 5 x 0.90
mg= 60mg which will be rounded off to
60 80ma
Administer the remaining 60.75/60.8 mg
(90%) in a 60 minute infusion

What is the possible Diagnosis of the patient? Hypertension and Atrial Fibrillation

FDAR
Date/Time Focus Progress notes

03/29/2022 Elevated blood

09:10am pressure D:
He was found down on the floor at 7:10 am by his wife.
Vital signs as follows BP= 200/110 mmHg. PR= 130 bpm

A:
 Assessed vital signs. Measured BP taken three readings,
 3 to 5 minutes apart while client is at rest, then sitting, and then
standing for reassessment using correct cuff size and accurate
technique.
 Recorded elevations in systolic as well as diastolic readings.
 Auscultated heart tones and breath sounds.
 Provided a calm, restful surroundings, minimize environmental
activity and noise.
 Planned activities to insert rest periods in between activities.
 Encouraged deep breathing exercises.
 Provided comfort measures, such as back and neck massage or
elevation of head.
 Instructed in relaxation techniques, guided imagery and distractions.
 Monitored response to medications that control BP.
 Administered medication as ordered.

R:
Participated in activities that reduce BP and cardiac
workload. Improved cardiac output as evidenced by blood
pressure of 182/90 mmHg and PR:94

Prepared by: K.A. San Joaquin- Delos Reyes, RN, MN