Name of Student :TEOPIZ, MARK JOVAN JR.

Section: BSN 3-A2

Concept: Case Study Individual

Clinical Instructor: Marie Christine Mercado

Patient’s Data

Name: Christian S. Nadela Nationality: Filipino

Gender: M Religion: Roman Catholic
Birthdate: July 20. 1933 Source of Data: SWU MEDICAL CENTER EMERGENCY ROOM RECORD
Birthplace: Cebu City Date & Time of Admission: 8/21/20 10:52 A.M,
Age: 87 Attending Physician: Dr. Yu Address: Punta Princesa Cebu City Diagnosis: CVD INFARCT
Educational Level: Marital Status: Married
Occupation: :

Chief Complaint: Vomiting, Elevated BP, Weakness, Cough

AOG:
EDC:
VITAL SIGNS: BP: 150/100, Temperature: 36.3 Pulse Rate: , RR: 24, 02 Saturation: 95% Weight:
Brief History Upon Admission:
Admitting Diagnosis: CVD INFARCT

Cerebrovascular Disease
The word cerebrovascular is made up of two parts – "cerebro" which refers to the large part of the brain, and "vascular" which means
arteries and veins. Together, the word cerebrovascular refers to blood flow in the brain. The term cerebrovascular disease includes
all disorders in which an area of the brain is temporarily or permanently affected by ischemia or bleeding and one or more of the
cerebral blood vessels are involved in the pathological process. Cerebrovascular disease includes stroke, carotid stenosis, vertebral
stenosis and intracranial stenosis, aneurysms, and vascular malformations.

Restrictions in blood flow may occur from vessel narrowing (stenosis), clot formation (thrombosis), blockage (embolism) or blood
vessel rupture (hemorrhage). Lack of sufficient blood flow (ischemia) affects brain tissue and may cause a stroke.

Signs and Symptoms

 Dizziness, nausea, or vomiting.

 Unusually severe headache.
 Confusion, disorientation or memory loss.
 Numbness, weakness in an arm, leg or the face, especially on one side.
 Abnormal or slurred speech.
 Difficulty with comprehension.
 Loss of vision or difficulty seeing.
 Loss of balance, coordination or the ability to walk.
Anatomy and Physiology

To begin with its simplest anatomical

classificatory scheme, the cerebral
circulation is composed of a supplying
arterial circulation and a draining
venous circulation. The arterial system
can then itself be subdivided according
to anatomical position, into anterior and
posterior cerebral circulations, as has
been discussed. One can also divide the arterial circulation by size. According to this scheme, the macrocirculation may be
considered to comprise the gross branches of the cerebral vascular responsible for the regional perfusion of the cerebrum. The
microcirculation is then derivatively defined as the microscopic site of oxygen and nutrient exchange within the vasculature, as well
as of the blood–brain barrier (BBB).[8] Continuing with the anatomical scheme, the microcirculation is terminally productive of the
brain's venous circulation: a freely communicating, interconnected system of dural venous sinuses and cerebral veins.[9,10] Although
the venous system is often given less attention than its arterial counterpart (likely due to the relevance of the latter to the topic of
ischemic stroke), it should not be forgotten that it, too, can serve as a significant focus of cerebral pathology, as is described below.
Beginning with the arterial supply, we will discuss each of these circulatory systems in detail.

Pathophysiology
Haemorrhagic strokes are due to the rupture of a blood vessels leading to compression of brain tissue from an expanding
haematoma. This can distort and injure tissue. In addition, the pressure may lead to a loss of blood supply to affected tissue with
resulting infarction, and the blood released by brain haemorrhage appears to have direct toxic effects on brain tissue and
vasculature.
 Intracerebral haemorrhage – caused by rupture of a blood vessel and accumulation of blood within the brain. This is
commonly the result of blood vessel damage from chronic hypertension, vascular malformations, or the use medications
associated with increased bleeding rates, such as anticoagulants, thrombolytics, and antiplatelet agents.
 Subarachnoid haemorrhage is the gradual collection of blood in the subarachnoid space of the brain dura, typically caused by
trauma to the head or rupture of a cerebral aneurysm.

COMPLETE BLOOD COUNT

TESTS RESULTS REF. RANGE INTERPRETATION

WBC 13.4 4.4 - 11.0 HIGH

NEU 11.74 1.80 – 7.80 HIGH

LYM 7.6 10.0 – 50.0 LOW

MON 3.7 0 – 12.0 NORMAL

EOS 0.8 0 – 7.0 NORMAL

BAS 0.2 0 – 2.5 NORMAL

RBC 4.08 4.50 – 5.90 LOW

HGB 13.0 14.0 – 17.5 LOW
HCT 39.4 41.5 – 50.4 LOW

MCV 97 80 – 96 HIGH
MCH 32.0 27.5 – 33.0 NORMAL
MCHC 33.1 32.0 – 36.0 NORMAL
RDW 11.4 11.6 – 14.8 LOW
PLT 281 150-450 NORMAL
MPV 8.2 6.0 – 11.0 NORMAL

Type of Exam Patient’s Normal Values Significance/

Results Interpretation

BLOOD HGT: 119 72 – 99 mg/ dL HIGH

GLUCOSE mg/dL BLOOD GLUCOSE
Poorly controlled
Diabetes
Type of Exam Patient’s Normal Values Significance/ Interpretation
Results

COMPLETE WBC: 13.4 4.4 – 11.0 HIGH

BLOOD COUNT
NEU: 11.74 1.80 – 7.80 HIGH

RBC: 4.08 4.50 – 5.90 LOW

HBG: 13.0 14.0 – 17.5 g/dl LOW

HCT: 39.4 LOW

41.5 – 50.4 %
Elevated WBC and neutrophil
indicates inflammation or
infection along the urinary tract,
often in the bladder or kidney.
Low RBC, HGB and HCT
indicates anemia.
PROTHROMBINE TIME

TEST RESULT REFERENC E RANGE INTERPRETATION

Patient 11.8 secs 9.2-13.2 NORMAL

Control 11.2 secs -

INR 1.05 0.82-1.11 NORMAL

% Activity 94.92 % 83-143 NORMAL

CLINICAL CHEMISTRY
TEST RESULTS UNIT REFERENCE RANGE INTERPRETATION

Sodium 131.0 mmol /L 136-145 LOW, result from vomiting

that makes muscles weak
Potassium 4.50 mmol /L 3.5-5.1 NORMAL

Chloride mmol /L 98-107

Calcium (Ionized) mmol /L 1.13-131

Calcium (Total) mg/dl 8.6-10.2

Magnesium mg/dl 1.7-2.4

Phosphorus mmol /L 2.4-4.5

Total Bilirubin mg/d L 0.18-1.23
Direct Bilirubin mg/d L 0.00-0.19

Indirect Bilirubin mg/d L 0.15-0.70

Creatinine O.82 mg/d L 0.51-0.95 NORMAL
Blood Urea Nitrogen 12.699 mg/d L 6.0-20.0 NORMAL
(BUN)
Blood Uric Acid 5.19 mg/d L 2.4-5.7 NORMAL
(BUA
Albumin mg/d L 3.97-4.94
Globulin mg/d L 1.5-2.5
Total Protein mg/d L 6.6-8.3
A/G Ratio - 0.8-2.0
HBA1C 5.70 % 4.0-6.0 NORMAL
ALT (SGPT) 30.44 U/L 0-41 NORMAL
AST (SGOT) U/L 0 -40
Alkaline Phosphat U/L 40 -129
ase (ALP)

Lactate Dehydrogen U/L 0-250

ase (LDH)
DRUG STUDY

Name of Mechanism of Action Indications Side Effects Nursing

the Drug Responsibilities
Generic Citicoline activates the Citicoline may be used for
Name biosynthesis of structural nutritional support in cerebral Citicoline may exert a Before
Citicoline phospholipids in the neuronal vascular diseases, head trauma, stimulating action of -Confirm physician’s order
membrane, increases cerebral stroke, and cognitive disorders. It the parasympathetic,  
  -Check and verify patient
metabolism and increases the also is used by those who have age as well as a fleeting
Brand to be administered
level of various related mental decline, such as and discrete
Name  
neurotransmitters, including Alzheimer’s and Parkinsons. hypotension effect. -Assess symptoms and
Zynapse acetylcholine and dopamine. . record baseline before
Dosage: Citicoline has shown administering drug.
neuroprotective effects in  
1 gm -Ask patient about past
situations of hypoxia and Contraindications
  allergies
ischemia. - Hypersensitivity to drugs  
Route:   During
IVTT   -Citicoline may be taken
  with or without food. Take
Frequency:
q 6H   it with or between meals.
   
  -Should not be taken in the
late afternoon or at night
because it can cause
difficulty sleeping.
 
-Administer drug as
indicated.
 
After
-Assist patient for any
signs of discomfort.
 
-Inform patient to report
immediately if allergic
reaction such as hives,
rash, or itching, swelling in
 the face or hands, mouth
or throat, chest tightness
or trouble breathing are

Drug Name Classification Mechanism of Indication Contraindicatio Adverse reactions Nursing

Action n Responsibilities
Generic Classification: Cephalosporins Pharyngitis/ Cefuroxime is Body as a Whole: Before:
Name: Second- exert bactericidal tonsillitis contraindicated in Thrombophlebitis (IV Check patient’s chart
activity by
Cefuroxime generation caused by patients with known site); pain, burning, Re-examine the
interfering with
cephalosporin bacterial cell wall Streptococcus allergies to the cellulitis (IMsite); medicine
Brand Name: synthesis and pyogenes cephalosporin superinfections, Verify the medication
Altoxime inhibiting cross- Otitis media group of antibiotics. positive Coomb’s test. Ask the patient for any
linking of the caused by Precautions: GI: Diarrhea, nausea, history of
peptidoglycan.
Dosage: Streptococcus hypersensitivity to antibiotic-associated allergy
The
1 tab 500mg cephalosporins pneumoniae penicillin, history of colitis. Check for physician’s
Route: are also thought Lower gastrointestinal Skin:Rash, pruritus, order
PO to play a role in respiratory disease, urticaria.
Frequency: the activation of infections particularly colitis, Urogenital:Increased During:
bacterial cell
BID caused by S. renal impairment serum cretonne and Give oral drug with
autolysins which pneumoniae BUN, decreased food to decrease
may contribute to UTIs caused by creatinine clearance GI upset and enhance
bacterial cell lysis
Escherichia coli absorption.
Uncomplicated Have vitamin K
gonorrhea available in case
(urethral and hypoprothrombinemia
endocervical) occurs.
Dermatologic Discontinue if a
infections, hypersensitivity
including reaction occurs
impetigo
caused by After:
Streptococcus Instruct the client to
aureus, S. swallow tablets whole;
pyogenes do not crush them. To
Treatment of take the drug with food.
early Lyme Instruct client to report
disease severe diarrhea with
blood, pus, or mucus;
rash; difficulty
breathing; unusual
tiredness, fatigue;
unusual bleeding or
bruising; unusual
itching or irritation.
Document and record
 Name of the Drug Mechanism of Action Indications Side Effects Nursing Responsibilities
Generic name: Inhibits the movement of Treatment of Before:
Amlodipine calcium ions across the hypertension; Used CNS: Light-headedness, -Obtain patient’s history to
membranes of cardiac and alone or in fatigue, headache. allergy of amlodipine.
 
combination with   -Monitor of BP and pulse before
arterial muscle cells;
Brand name: other therapy, during dose titration,
Norvasc inhibits transmembrane calcium CV: Palpitations,
antihypertensives and periodically during therapy
flow, which results in the agent; Treatment flushing tachycardia, -Monitor ECG periodically during
 
depression of impulse of diabetic peripheral or facial prolonged therapy.
Classification: formation in specialized cardiac nephropathy with edema, bradycardia, -Monitor intake and output
Cardiovascular pacemaker cells, slowing of the an elevated chest pain, syncope, ratios and daily weight.
agent; Calcium velocity of conduction of the creatinine postural hypotension. - Lab test considerations: total
channel blocker; and proteinuria (in   serum calcium concentrations
cardiac impulse, depression of
Antihypertensive pts with type 2 are not affected by calcium
myocardial contractility, and diabetes and GI: Abdominal pain, channel blockers.
agent
dilation of coronary arteries and history of nausea, anorexia, During:
  arterioles and peripheral hypertension), constipation, - Monitor BP for therapeutic
Dosage: arterioles; these effects lead to prevention of dyspepsia, dysphagia, effectiveness.
decreased cardiac work, stroke in pts with diarrhea, flatulence, -Monitor for S&S of dose-related
2.5 mg, 5 mg, 10 mg. hypertension and peripheral or facial edema that
decreased cardiac oxygen vomiting.
  left ventricular may not be accompanied by
consumption, and in patients  
hypertrophy. weight gain.
Frequency:OD with vasospastic (Prinzmetal’s) Respiratory: Dyspnea -Monitor BP with postural
  angina, increased delivery of   changes.
Route: PO oxygen to cardiac cells. Urogenital: Sexual -Position the pt in an upright
dysfunction, frequency, position to minimize orthostatic
 
nocturia. hypotension.
Timing: After:
 
Preferably morning - Report significant swelling of
Skin: Flushing, rash. face or extremities.
May give without   -Take care to have support when
regard to food. Other: Arthralgia, standing & walking due to
  cramps, myalgia. possible dose-related light-
  headedness/dizziness.
  -Report shortness of breath,
palpitations, irregular heartbeat,
nausea, or constipation to
physician.
-Record and Document.
Patient Teaching:
- Compliance with therapy
regimen is essential to control
hypertension.
- Avoid tasks that require
alertness, motor skills until
response to drug is
established.
-Do not ingest grapefruit
products. 
Drug Name Classification Mechanism of Indication Contraindicatio Adverse Nursing
Action n reactions Responsibilities
Generic Proton pump Inhibits both Duodenal Known Occasionally Assess underlying
Name: inhibitors. basal and and gastric hypersensitivity to headache or condition before
stimulated gastric ulcer, any of the diarrhea. therapy and
Pantoprazole acid secretion by moderate and constituents of Isolated cases of thereafter to monitor
suppressing the severe reflux Pantoloc or of the edema, blurred drug effectiveness.
Generic final step in acids esophagitis. combination vision, fever, Assess GI
name: production, Eradication of partners. Mild dizziness, symptoms:
through the H. pylori in gastrointestinal thrombophlebitis, epigastric/abdominal
Pantoloc inhabitation of the patient with complaints eg, depression or pain, bleeding and
proton pump by peptic ulcer, nervous dyspepsia. myalgia anorexia. Monitor for
binding to and pathological Pantoloc must not subsiding after possible drug
Patient
inhibiting hyper be used in termination of induced adverse
dose:
hydrogen- secretory combination therapy. reaction.
40 mg IVTT/1
potassium conditions. treatment for
vial, after
adenosine Symptomatic eradication of H.
breakfast
triphosphatase, improvement pylori in patients
the enzyme and healing with moderate to
system located at of mild reflux severe hepatic or
the secretory esophagitis. renal dysfunction.
surface of the Prevention
gastric parietal gastro-
cell. duodenal
ulcers
induced by
NSAID in
patients at
risk with a
need for
continuous
NSAID
 treatment.

NURSING CARE PLAN

Defining Nursing Scientific Goal of Care Intervention Rationale Evaluation
Characteristics Diagnosis Analysis
Subjective: Decreased . Activity Independent: After 2 hours of nursing
  activity intolerance can Short term: 1. Note the 1. . Fatigue affects intervention the patient was
“I feel so weak” intolerance be described as After 2 hours of presence of both the client’s able to verbalize
as verbalized by related to insufficient nursing intervention factors actual and understanding and maintain
the patient. generalized physiological or the patient will be contributing to perceived ability to the blood pressure of at
  weakness as psychological able to: fatigue participate in least 100/60. (Goal met)
Objective: evidenced by energy to 1. Patient will 2. Assess the activities.  
  verbal report of complete required verbalize patient’s 2. Noting pulse rate After a week of nursing
-weakness fatigue or or desired daily understanding response to more than 20 beats intervention the patient was
-vomiting weakness. activities. Activity about the health activity per min faster than able to participate in
BP: 150/100 intolerance is a teaching and its   resting rate; desired activities and
RR: 24 common side importance.   marked increase in increase their activity
HCT: 39.4 effect of heart 2. The patient will   BP during and after tolerance. They also
HGB: 13.0 failure and can be maintain a blood 1. Assess activity demonstrate a decrease in
related to pressure of at least emotional and 3. Stress physiological signs of
generalized 100/60 physiological or depression may intolerance. (Goal met)
weakness and Long term: factors be increasing the
difficulty resting After one week of affecting the effects of an illness,
and sleeping. nursing intervention current or depression might
  the patient will be situation be the result of
Source: able to:   being forced into
https://simplenur 1. Patient will Dependent: inactivity
sing.ph/nursing- participate in 1. Give D50W as  
intervention-for- necessary/desired ordered by the 1. D50W product is
activities physician. used to treat low
activity-
2. Patient will   blood sugar levels.
intolerance report a Collaborative:  
measurable 1. Assist doctors  
increase in with the 1. To make things
activity procedures easier for the
tolerance. health care
The patient will providers
demonstrate a
decrease in
physiological signs
 of intolerance

Defining Nursing Scientific Goal of Care Intervention Rationale Evaluation

Characteristics Diagnosis Analysis
Subjective Cues: Disturbed Dementia is a After 8 hours of Independent: 1. Confusion may
“Asa ko karon?” thought process general term for appropriate nursing 1. Assess level range from slight
As verbalized by related to the impaired intervention, the of confusion disorientation to
the patient. impaired ability to patient will: and agitation and may
  memory as a. Identify disorientation. develop over a
remember,
  evidence by ways to 2. Assess patient short period of time
Objective Cues: disorientation. think, or make compensat for sensory or slowly over
- Received decisions that e for deprivation, several months.
diphenhy interferes with cognitive concurrent use May indicate
dramine doing everyday impairment of CNS drugs, effectiveness of
50 activities. and poor nutrition, treatment or
mg/amp Alzheimer's memory dehydration, decline in condition.
1 amp disease is the deficits. infection, or 2. May cause
IVTT most common Demonstrate other confusion and
- Laborato type of behaviors to concomitant change in mental
ry test minimize changes disease status.
dementia.
result of in mentation processes. 3. If the needs of a
Though 3. Maintain a patient with AD are
sodium
is below
dementia mostly regular daily not met, it may
the affects older schedule cause the patient to
normal adults, it is not a routine to become agitated
range. part of normal prevent and anxious.
(131 aging problems that Predictable
mmol/L) may result behavior is less
- Patient is from thirst, threatening to the
disorient hunger, lack of patient and does
ed on sleep, or not tax limited
place. inadequate ability to function
exercise. with ADLs.
   
Dependent:  
1. Administer N- 1. The only drug in
Methyl-D- the N-methyl-D-
 Aspartate aspartate (NMDA)
antagonists as antagonist class
ordered. that is approved by
2. Help and the US Food and
guide patient Drug Administration
perform his is memantine; this
routine agent may be used
physical alone or in
activity combination with
prescribed by AChE inhibitors.
the physician. 2. Routine physical
activity and
exercise may have
an impact on
dementia
progression and
may perhaps have
a protective effect
on brain health; the
patient’s
surroundings
should be safe and
familiar;
maintaining
structured routines
may be helpful to
decrease patient’s
stress in regard to
meals, medication,
and other
therapeutic
activities aimed at
maintaining
cognitive
functioning.