Cerebral Infarction (Left), Acute and Subacute

Infective Endocarditis
_________________________________________
A Case Presentation
Presented to the
College of Nursing
St. Jude College Dasmariñas Cavite, Inc.
Dasmariñas Cavite, Philippines
__________________________________________________
In Partial Fulfillment
of the requirements for the Subject
Medical Surgical Nursing
_______________________________________________

Presented by:
Artista, Monique

Chavez, John Kenneth C.

Cuaresma, Krisel B.

Dumalan, Mary Joyce

Habilag, Emmanuel C.

Timbol, Angela Monique S.

BSN LEVEL IV
TEAM B
BATCH 2022
Table of Contents

I. INTRODUCTION............................................................................................................................... 3
II. BIOGRAPHICAL DATA ................................................................................................................. 5
A. Genogram ................................................................................................................................... 6
III. HISTORY OF PAST AND PRESENT ILLNESS ....................................................................... 7
A. Past Medical History ................................................................................................................ 7
B. Present Medical History .......................................................................................................... 7
IV. ASSESSMENT ............................................................................................................................... 8
A. General Assessment:............................................................................................................... 8
B. Physical Assessment (Head to Toe Assessment) ........................................................... 9
C. Gordon’s Functional Pattern of Assessment .................................................................. 33
VI. LABORATORY AND DIAGNOSTIC ........................................................................................ 51
V. ANATOMY AND PHYSIOLOGY ................................................................................................ 56
VII. PATHOPHYSIOLOGY ............................................................................................................... 88
VIII. NURSING CARE PLAN............................................................................................................ 92
A. Prioritization ............................................................................................................................. 92
B. Nursing Care Plan ................................................................................................................... 95
X. DRUG STUDY ............................................................................................................................. 143
Xi. DISCHARGE PLAN ................................................................................................................... 170
I. INTRODUCTION

Rheumatic heart disease is the long-term damage to the heart valve that follows
acute rheumatic fever. Rheumatic heart disease is an autoimmune disease that
follows throat infection or reinfection with the bacterium group A streptococcus, or
Rheumatic Heart Disease, which occurs most often in school age children, follows 0.3%
to 3% of cases of group A beta-hemolytic streptococcal infection (Chin, 2011). Prompt
treatment of strep throat with antibiotics can prevent the development of rheumatic
fever. Streptococcus bacteria is spread through contact with oral or respiratory
secretions. Mostly, the predisposing factors are malnutrition, overcrowding, and lower
economic status may predispose individuals to rheumatic fever. Although Rheumatic
heart disease has almost disappeared from industrialized and wealthy countries, it
remains the most frequent heart disease in children worldwide. According to the latest
WHO data published in 2020 Rheumatic Heart Disease deaths in Philippines reached
1,807 or 0.27% of total deaths. The age adjusted death rate is 1.81 per 100,000 of
population rank Philippines #75 in the world.

Endocarditis is an infection of the endocardium, which is the inner lining of the heart
chambers and heart valves. It generally occurs when bacteria, fungi or other germs
form another part of the body, such as mouth, spread through the blood. Endocarditis
is fatal without treatment. Ineffective endocarditis can be either acute or subacute.
Acute ineffective endocarditis can develop and become life-threatening within days.
Subacute ineffective endocarditis develops slowly over a period of several weeks to
several months. Ineffective endocarditis has an incidence rate of 3-10 cases in every
100,000 people. No race or ethnicity is more affected than others. Ineffective
endocarditis appears to be approximately twice as common in men as women. In the
past, disease onset occurred at an average age of 35 years of age. However, with
more patient having artificial heart valves and pacemakers, the average onset has
increase over to 50 years old. Prognosis of ineffective endocarditis remains poor
despite advances in diagnosis and therapies. Mortality rates are approximately 25%
even with the best therapies available. Endocarditis can also be noninfective. In non
infective endocarditis, blood clots that do not contain microorganism form on heart
valves and adjacent endocardium. Noninfective endocarditis sometime leads to
infective endocarditis because microorganisms can attach to and grow within the
fibrous blood clots.

Rheumatic heart disease is a risk factor for ineffective endocarditis. In developing

countries, heart damaged cause by rheumatic heart disease is the leading
predisposing condition for ineffective endocarditis, however in developed countries,
rheumatic heart disease is implicated in less than 5% of ineffective endocarditis cases.
Cerebral infarction as a complication if infective endocarditis results from the
embolization of endocardial vegetation with consecutive occlusion of an intracerebral
artery. Dissemination of the emboli into cerebral or meningeal vessels can further lead
to meningitis or intracerebral abscess formation. a study reveals that the incidence of
first ever ischemic stroke in adolescents >10 to <18 years of age in the catchment
population was 0.6 per 100,000 adolescents per year and 0.91 per 100,000
adolescents/year in the general population.

Our group chose this study because it is an interesting topic to study. This study
aims to develop the knowledge and skills through utilization of nursing process. This
case study and the knowledge we had acquired will help the group in acquiring
sufficient information and apply it in the actual hospital setting to the patient with the
same diagnosis.
II. BIOGRAPHICAL DATA
A. Patient’s Name : M.P.M.V
B. Address : Paliparan III, Dasmarinas City
C. Age : 20 years old
D. Birthdate : July 8, 2001
E. Birthplace : Dasmarinas City
F. Gender : Male
G. Civil status : Single-
H. Religion : Catholic
I. Highest Educational Attainment: Senior High School
J. Nationality : Filipino
K. Occupation : None
L. Primary Informant : Patient M.P.M.V
M. Secondary Informant : Sister
N. Other Sources : Patient’s Chart
O. Date and Time of Admission : April 12, 2022 | 10:20 PM
P. Chief Complaint : Right Sided Body Weakness
Q. Initial Diagnosis : CVD Infarct, Left Basal Ganglia
R. Final Diagnosis : Cerebral Infarction, Acute and
Subacute Ineffective Endocarditis
 A. Genogram
M.L.P 69y/o D.V.P 66 y/o D.V 61 y/o
K.F.A 63 y/o
COVID-19 hypertensive
Cardiac arrest

K.V

I.P 35 y/o 45 y/o

A.B.P 43 y/o
D.P 40 y/o

M.P
M.A.P 25 y/o
M.P 23 Y/O M.P.V 20 y/o M.C 19 y/o
22 Y/O

LEGEND:
M.V 4 y/o
MALE FEMALE MALE FEMALE
PATIENT
ALIVE DECEASED DECEASED
ALIVE

Patient M.P.M.V was diagnosed with Cerebral Infarction; Acute and Subacute
ineffective endocarditis. On the maternal side of the patient, his grandmother died at the
age of 69 due to COVID-19 complications, at the age of 66, his grandfather died due to
cardiac arrest. On the maternal side, his mother A.P.V 43 years old has 2 siblings. D.P 40
years old and I.P 35 years old. Patient’s sister reported that his mother’s sibling doesn’t
have any diseases and living a healthy lifestyle. Moving on to the paternal side, the patient’s
sister reports that their grandmother K.F.A is 63 years old and was known as hypertensive
and verbalized that their grandmother K.F.A is compliant to her maintenance medication.
His grandfather D.V 61 years old is alive and living well. His father is an only child 45 years
old and living well together with their family. Patient M.P.V has 3 sibling, and he is the
youngest. Patient M.P.V had his first child at the age of 16. Patient M.P.V was diagnosed
with Rheumatic heart disease last 2015.
III. HISTORY OF PAST AND PRESENT ILLNESS
A. Past Medical History
Patient MPBV was diagnosed with rheumatic heart disease in 2015. The patient
was on regular Penicillin G injection every 21 days since 2015 in UMC. According to
the patient’s sister, “Nung bata yan, madalas yan may tonsil, madalas din
tinatrangkaso”. For his maintenance medication he takes Lanoxin and enalapril.
Patient’s sister also states that patient MPBV was also epileptic, he takes medication
for his seizure, but forgot the name of the medicine. According to Patient MPBV, before
the seizure starts, he experiences ascending paraplegia, his sister states that the
seizure lasts for 2 mins and describes the seizure as “para siyang naninigas tapos,
ayun nag seizure na”. And when asked about the first time of the seizure, he manages
his brother by putting a spoon in the mouth, and ask for help. No reported, seizure
episode from 2016 up to succeeding years, but last April 4, 2022, patient MPBV,
experiences seizure in the Emergency Room of Pagamutan ng Dasmarinas. Patient
MPBV started to take his seizure medication at 2015 and reports to stop taking it at
2016. During his general checkup last November. 2021, patient MPMV reported that
he had a slightly increased blood pressure, blood glucose, and increased uric acid.
Which led his dr to prescribe allopurinol but after a month, he stop taking this
medication since his uric acid was normalized after a month. The patient has a old
healed fracture on the Right middle 3rd segment of the ulna and stated that the patient
got this during basketball in 2014. According to the patient, he likes to eat street foods
like calamares and pares, and states that he always brings his medication with him.

B. Present Medical History

Patient MPBV’s initial diagnosis was CVD Infarct left basal ganglia probably
cardio embolic, and his final diagnosis was Cerebral Infarction, Acute and Subacute
Ineffective Endocarditis. The patient was admitted to the emergency room of
Pagamutan ng Dasmarinas last April 4, 2022, and was admitted to Room of choice
last April 12, 2022. The patient experienced sudden onset of right sided body
weakness that spontaneously resolved, but after 8 hours, the patient experienced
recurrence of right sided body weakness that caused the patient to become non
ambulatory, persistence of symptoms led to consult. Baseline vital signs are BP:
110/70, PR: 103 RR: 28 temperature: 37.4 SPO2: 98%. The patient’s sister states that
2 days before he experiences right sided body weakness, he had his shot of Peniciliin
G. upon admission to the ER, the doctor orders PNSS for his IV fluids. He was on
Nasogastric tube and was placed on temporary NPO, for his therapeutics the doctor
orders, omemprazole 40 mg/IV OD, atorvastatin 80 mg/tab ODHS, Citicoline 1gm IV
q12, and was advised to continue maintenance meds (lanoxin, and enalapril). On April
3, 2022, the patient was still reporting Right sided body weakness, but there is no
decrease in Level of consciousness, no headache and no vomiting. The patient was
hooked to cardiac monitor. On April 4, 2022, the patient’s sister stated that he had
experience seizure, he describes the seizure as “nakatulala lang siya, di ko nga alam
na seizure na yun eh, nag kakaganon siya ng 10 sec tas nangyari yun ng mga 3x”.
Day 1 post ictus April 5, 2022, the patient was drowsy but arousable to name calling
and follows simple command. On April 6, 2022, the patient was fully awake, coherent
but noted to have slurred speech and right hemiplegia but there is a spontaneous
movement of right body. On April 7, 2022 the patient complains of pooling of secretions
on the throat, and the secretion was described as whitish on color. Still on Nasogastric
tube, the doctor orders ciprofloxacin, and NAC for the patient’s secretion. On April 8,
2022, the patient was awake, and conscious, he follows command but experiencing
dysarthria still with Right hemiplegia. On April 10, 2022, the patient has pleghm,
experiences headache, and dizziness. The doctor orders, betahistine. On April 11,
2022, the patient has improvement on motor skills, no new report of neurologic deficit,
but complains of dry cough. The patient’s lab confirms that he has (+) RHD, (+)
endocarditis. Ciprofloxacin was discontinued and ceftriaxone was started. On April 13,
2022, the patient was noted to have an improvement, no noted dysarthria, but sill have
Right hemiplegia. Citicholine was discontinued. The patient is fully vaccinated with
Pfizer, upon admission, nasopharyngeal swab was taken, and the patient was
negative for SARS-COV 2.

IV. ASSESSMENT
A. General Assessment:
Patient M.P.M.V is a 20-year-old male. Patient has pulse rate of 103 bpm,
respiratory rate of 28 cpm, temperature of 37.4°C, blood pressure of 110/70 and an
oxygen saturation of 98%. With ongoing PNSS 1 L 60 cc/hr on Left metacarpal vein.
The patient was positioned in high fowlers, and has diaper. Patient is coherent,
cooperative, but there is a time that the patient was having a blank stare and slurred
speech, but he is able to answer the questions being asked by the student nurses.

Vital Signs
Temperature 37.4
Pulse Rate 103
Respiratory rate 28
Blood pressure 110/70
Spo2 98%
Height 167.64 cm
Weight 53 kg
BMI 19 kg/m2 - underweight
PAIN SCALE
Provoking Factor Fatigue and lack of sleep and decreased cerebral
perfusion
Quality Throbbing headache
Radiation doesn’t radiate
Severity 6/10
Time It lasts for several minutes,

B. Physical Assessment (Head to Toe Assessment)

BODY PART ACTUAL FINDING NORMAL FINDING CLINICAL
EXAMINED SIGNIFICANCE
SKIN
I: Color, I: The patient has I: Varies from light to Decreased
uniformity, edema, fair skin, but the skin deep brown; cardiac supply of
lesions is not uniform in generally, uniform in the blood due to
color. Palmar area areas exposed to the disease
of the patient is sun; no edema and process causes
slightly cyanotic. No lesions decrease blood
presence of edema supply in other
in both extremities. organs.
There is a healed Alteration of
lesion noted on the kidney function
left patellar part of causes
the patient. decrease
production of red
blood cells,
which decreases
oxygen
circulation in the
body that leads
to Hypoxia.
According to
Brunner &
Suddarth
(2004), The
usual cause of
hypoxia is
ischemia, or
deficient blood
supply. Ischemia
also results from
intravascular
clots (thrombi or
emboli) that may
form and
interfere with
blood supply.
Thromboemboli
c are common
causes of
cerebrovascular
accidents.
Embolization of
endocardial
vegetation
builds up which
causes blockage
in the
 intracerebral
artery which also
causes cerebral
hypoxia.

Patient had an
injury last 2015
because of
playing
basketball, with
this healed
lesion is seen
with the patient.
P: Moisture, P: Skin is slightly dry Moisture in the skin The patient’s
Temperature, and it is warm to folds and in the skin is slightly
Turgor touch. Temperature axillae; normal range dry because of
was taken via of 36.5-37.6; when his prolonged
infrared pinched, skin stay in the
thermometer 36.7 springs back to hospital.
C. Skin turgor is previous state According to
checked in the Cobb (2017), a
abdomen of the person who
patient; the skin stays in the
returns rapidly to its hospital does
normal position (<1 not taking a bath
sec.) and not wash
one or more
areas of the
body can cause
dead skin cells.
Dead skin cells
build up in
patches of skin
 that are often
dark, scaly and
rough. Normal
skin turgor was
seen on the
patient, and
normal
temperature was
noted, which
indicates normal
findings.
HAIR
I: evenness of I: Hair is evenly Evenly distributed This indicates
growth, texture, distributed. No hair, thick, silky, and normal findings.
oiliness, infection generalized hair resilient hair; No Long periods of
or infestation, loss was noted. Hair infection or time without
body hair is slightly oily. No infestation; fine, washing the hair
infection or medium, or coarse will cause a build
infestation noted. texture up of natural oils.
The patient
doesn’t manifest
infestation and
infection on the
hair. According
to Cobb (2017),
when you don’t
wash your hair,
oils may
accumulate on
the scalp.
P: Smoothness P: hair is smooth, no Smooth hair with no Smooth hair,
nodules or masses manifestations. with no nodules
or masses noted
 noted in the head of indicates normal
the patient. findings.
NAILS
I: Plate, shape, I: Nails are trimmed Convex curvature; Patient
texture, bed color, and clean. Nail beds Smooth texture; manifests pale
surrounding are slightly pale. Highly vascular and nailbeds, which
tissues The nail plate pink in light skinned indicates poor
appears flat but clients; dark skinned tissue perfusion.
there is longitudinal clients may have Due to the
ridging observed. brown or black decrease
pigmentation cardiac output,
there is
decreased
stroke volume,
thus results to
decreased blood
pumped out
from the blood.
According to
Brunner &
Suddarth
(2004), low red
blood cell count
can cause pale
nails. Decrease
blood supply in
the other organs
results to
decrease
oxygen
circulation that
leads to hypoxia.
P: Blanch test P: Capillary refill, 4 Prompt return of pink Prolonged
seconds. or usual color capillary refiled
(Generally less than indicates low
2 seconds) cardiac output
that leads to
hypoxia. Poor
oxygen in the
tissues
increases the
capillary refill
time.
HEAD
Skull and Face I: The patient’s head Normocephalic. : Facial
is round, upright, symmetrical : No asymmetry is a
I: size, shape, and still. Facial presence of edema common
symmetry asymmetry is noted. manifestation of
: Facial features Facial features on neurologic
: Eyes for edema the lower right side disease. In
and hollowness of the face are not stroke cases, it
symmetrical to the happens as a
left side of the face. result of
Eyes have no signs impaired facial
of hollowness and nerve.
edema, however According to
eyebags were Brunner &
noted. Suddarth
(2004), face
drooping is one
of the most
common sign of
stroke. One side
of the face may
become numb or
 weak. Facial
nerve
impairment can
cause
weakness, such
as drooping of
the mouth,
slurred speech,
decreased
sensation, and
difficulty of
swallowing.
P: Nodules, P: No nodules, No presence of Absence of
masses, and masses, and Nodules, Masses, nodules,
depression depressions noted. and depressions masses, and
depression
indicates normal
findings.
EYES AND VISION
I: Eyebrows for I: Eyebrows are Hair is evenly Due to the spinal
distribution and evenly distributed distributed; Skin is decussation, left
alignment, quality, and are aligned. intact. Eyebrows is side of the face
and movement Eyebrow, on the left symmetrical aligned, demonstrates
side can move up equal movement facial muscle
and down weakness.
independently, According to
however, the patient Brunner &
has difficulty in Suddarth
moving his right (2004), face
eyebrow. drooping is one
of the most
common sign of
stroke. One side
 of the face may
become numb or
weak. Facial
nerve
impairment can
cause
weakness, such
as drooping of
the mouth,
slurred speech,
decreased
sensation, and
difficulty of
swallowing.
: Eyelashes for Eyelashes are Equally distributed; This indicates
evenness of evenly distributed, curl slightly outward normal findings
distribution and and direction of curl
direction of curl. is outward
: Eyelids for : Dry eyes are approximately 15-20 Dry eyes
surface noted, blinking is involuntary blinks per following stroke
characteristics, slower than usual min; bilateral can be due to
position in relation blinking; when lids problems with
to cornea, ability to open no visible the nerves of the
blink and sclera above cornea eyelid, the facial
frequency and upper and lower nerve or the
border of cornea are muscle of the
slightly covered; eyelid. The rate
Transparent of blinking may
capillaries; be slower
sometimes evident; following a
sclera appears white stroke.
(yellowish in dark According to
skinned people) Maher (2019),
 sometimes
stroke patient’s
don’t blink
because they
have lost the
involuntary
movement.
I/P: Lacrimal gland : Lacrimal gland sac, Shiny, smooth, and This indicates
sac, nasolacrimal nasolacrimal duct pink or red; It should normal
duct for edema, has no signs of appear pink and findings.
tenderness/tearin edema, tenderness, moist. No signs of
g and tearing edema, tenderness,
and tearing
I: Cornea for : Decrease in Clear and very Affectation of
clarity, texture, corneal reflex sensitive nearby motor
and sensitivity area can cause
decrease in
corneal reflex.
The corneal
reflex may be
slowed in
various
disorders
affecting
trigeminal nerve
(Swartz, 2021).
I: Pupils for color, : Pupils are brown Usually color brown;
shape, symmetry f and equally round. Rounded pupil;
size, direct and There is a Symmetrical size.
consensual diminished pupil Pupil equally, round,
reaction to light response in light and reactive to light
and and accommodation
accommodation
 EARS AND HEARING
I: auricles for I: Auricles are I: Color same as This indicates
color, symmetry, uniform in skin color. facial skin; normal findings.
and position Auricles position symmetrical; auricle
was aligned to the aligned with the
inner canthus of the outer cantus of eyes
eyes. External canal : Distal third contains
has slightly amount hair follicles and
of brown cerumen, glands; Dry
no lesions, pus, or cerumen, Grayish-
blood noted. tan color, or sticky
wet cerumen in
various shades of
brown
P: Auricles for P: Auricles are Normal voice tones The patient can
texture, elasticity, slightly elastic and audible: Able to hear hear clearly,
and areas of not that tender. Able ticking in both ears however there is
tenderness to hear clearly and a problem with
well but sometimes, the patient’s
the patient asks the comprehension.
student nurse to The sensory
repeat the question speech area is
again. still intact but still
impaired
because of the
damage to the
cerebral
hemisphere of
the brain.
According to
Brunner and
Suddarth
(2004), if
 damage as
occurred to the
frontal lobe,
learning
capacity,
memory or other
higher cortical
intellectual
functions may
be impaired.
Such as
difficulties in
comprehension.
NOSE AND SINUSES
I: Nose deviation I: The skin is smooth Symmetric and This indicates
in shape, size, without swelling and straight; no normal
color, flaring, conform to the color discharge or flaring findings
discharge of the face. No noted uniform color. :
: Nasal mucosa for discharge in the Mucosa is pink; No
redness, swelling, nares and no noted swelling; No
growth or flaring or narrowing. presence of
discharge discharge
P: tenderness, P: No noted Not tender; No This indicates
masses, tenderness, lesions. Air moves normal
displacements masses, and freely as the client findings
: nasal patency displacement in the breathes through the
nose. The nasal nares
structures are firm
and stable to
palpation without
crepitus.
Nasal breathing was
noiseless and easy
 through the open
nares.
: maxillary and there is a mild sinus, No tenderness when Based on the
frontal sinuses for both ethmoid and sinus is palpated. MRI of the
tenderness maxillary sinus. patient there is a
mild sinus on
both ethmoid
and maxillary
sinus. This
happens due to
inflammation of
paranasal sinus
caused by toxin
in cilla. Mucus
overflows from
sinus. According
to Fisher (2019),
people often
develop sinusitis
after they have a
common cold. If
the lining of the
sinus becomes
blocked in a
cold, the mucus
gets thick and
sticky. The sinus
may not drain
properly and
bacteria can the
buildup in the
mucus.
MOUTH AND OROPHARYNX
I: Lips for I: Lips are dry, small I: Uniform pink color; Lips are dry
symmetry of in shape, Soft, Moist smooth because the
contour, color, symmetrical, and texture; symmetry of patient has diet
texture, moisture, pale in color. contour; ability to precaution.
lesion purse lips Which is DAT
with SAP. With
the strict
aspiration
precaution in his
diet, the patient
has limitation
when it comes to
his diet.
teeth for Crowding of the : 32 adult teeth, This indicates a
alignment, loss, teeth was observed, smooth, white, shiny normal finding.
dental filings and and yellowish in tooth enamel, pink
carries color gums; moist firm
texture to gums
gums for bleeding, gums are not ; no retraction of This indicates a
color, retraction, bleeding, no lesions gums: Smooth normal finding
lesions, swelling and no swelling tongue base with
noted. prominent veins :
Same as color of
buccal mucosa and
floor of mouth
tongue for tongue is aligned : Positioned in This indicates a
position, color & within the mouth, midline of soft palate normal finding
texture; texture is soft, as
movement, as well well as base of the
as the base of the tongue
tongue, mouth
floor and frenulum
salivary gland salivary gland ducts Salivary glands are This indicates a
ducts for swelling are not swelling not swelling normal finding
redness
: palates for color, palates are pink in : Light pink, smooth, This indicates a
shape, texture, color, has normal soft palate lighter normal finding
presence of bony wave like structure pink hard palate,
prominences and presence of more irregular
bony prominences. texture

uvula for position uvula is positioned : Positioned in This indicates

and mobility at the middle of the midline of soft palate normal findings
mouth when
opened, pink in
color
: oropharynx for pink in color, no Should be pink in This indicates
color and texture lesion noted normal findings.
tonsils for color, tonsils are reddish in Present gag reflex. This indicates a
discharge and size color, normal finding.
** Test for gag tonsil: grade 0 Although stroke
reflex Normal gag reflex, patient may
patient can tolerate experience
soft diet. impaired gag
reflex. When a
stroke damages
the part of the
brain that
controls the
throat muscle,
the brain cannot
send the signals
to the muscle
anymore. As a
 result it can
affect the ability
to swallow. That
is why the
patient is placed
in a strict
aspiration
precaution, in
case the disease
impairs his gag
reflex.
P: Nodules, lump, No nodules, lump, No nodules, lumps, This indicates
and excoriated and excoriated and excoriated areas normal findings
areas areas

NECK
I: abnormal I: No signs of Muscles equal size; This indicates
swelling or swelling on both head centered; normal findings
masses, head sides of the neck. Coordinated, smooth
movement, and Patient can tolerate
muscle strength head movement,
without pain.
P: Lymph node P: No noted No lymph nodes This indicates
enlargement tenderness of the should be palpable normal findings
lymph nodes.
P: Trachea P: midline deviation Central placement in This indicates
of trachea midline of neck normal findings
spaces is equal on
both sides

I: Symmetry and I: Symmetrical and a Lobe may not be This indicates

visible masses, visible mass and palpated if palpated; normal findings.
lobes are small,
rise during rising during smooth centrally
swallowing swallowing located, painless
and rise freely with
swallowing: absence
of bruit
Thorax and Lungs (Posterior Thorax)
I: Shape and I: The bony Anteroposterior to This indicates
symmetry from framework is transverse diameter normal findings
posterior-lateral obvious, the in ratio of 1:2; Chest
views: spinal clavicles are is symmetrical;
alignment for prominent Spine vertically
deformities superiorly, the aligned
sternum are flat.
Pa: temperature, Pa: no noted No presence of Fremitus
bulges, tenderness on the bulges, tenderness, increases
tenderness, tactile patient’s posterior and abnormal because of the
fremitus thorax. Increased movement 3- 5cm consolidation of
fremitus was noted respiratory the mucus in the
upon checking the excursion; good and lungs. Due to the
tactile fremitus. strong fremitus irritation of the
airway because
of the mucus
overflowing from
the sinus, It
stimulates the
goblet cells
which produces
mucus.
According to
Seidel (2013),
more tremulous
fremitus than
expected occurs
 with some lung
consolidation
and some
inflammatory
and infectious
process.
Pe: for symmetry Pe: remainder of the Percussion notes This indicates
of resonance; lung fields is clear in resonate, except normal
diaphragmatic posterior. Same over scapula; findings
excursion normal sound is Excursion is 3 to 5
heard bilaterally cm bilaterally in
women and 5 to 6 cm
in men
A: breath sounds A: diminished Vesicular and Crackles are
bilateral breath Broncho vesicular heard over the
sounds are heard. breath sound lungs because
Crackles are also of the
heard over the consolidation of
posterior thorax the mucus.
upon inspiration.
Thorax and Lungs (Anterior Thorax)
I: breathing I: Patient’s Quiet, rhythmic, and The patient
pattern, coastal respiratory rate is 28 effortless presents
and costovertebral cpm, this indicates respirations; coastal hypoxia, due to
angle tachypnea decrease
oxygen
circulation. With
that it increases
oxygen demand
that causes
increase
respiratory rate.
According to
 Brinkman
(2022), hypoxia
induces
breathing
pattern of rapid
and shallow
breaths with a
relatively higher
increase in
respiratory rate
than tidal
volume.
Pa: temperature, no noted tenderness no noted tenderness This indicates
bulges, on the patient’s on the patient’s normal findings
tenderness, anterior thorax. anterior thorax.
abnormal
movements,

Pe: symmetry of Pe: remainder of the Percussion notes This indicates

resonance lung fields is clear in resonate down to the normal findings
posterior. Same sixth rib at the level
normal sound is of the diaphragm but
heard bilaterally flat over areas of
heavy muscles and
bone; dull on areas
over heart as the
liver tympanic over
the underlying
stomach.
A: breath sounds A: diminished Normal breath sound Crackles are
bilateral breath should be heard heard over the
sounds are heard. bilaterally. There lungs because
Crackles are also should be no of the
 heard over the crackles upon consolidation of
anterior upon auscultation the mucus.
inspiration.
HEART
I: Precordium for Pulsation and lifts or No presence of lifts This indicates
pulsation and lifts heaves are not or heaves normal findings
or heaves present
A: Heart sounds Grade II-III systolic No murmur sound Mild tricuspid
(s1, s2 etc.) murmur at mitral regurgitation
area. happens due to
Holosystolic murmur the thrombus
on the over tricuspid formation on the
area cardiac valves
which causes
holosystolic
murmur on the
tricuspid area.

Grade II-II
systolic murmur
at the mitral area
because of the
regurgitation of
the blood flow in
the mitral valve
due to mitral
valve prolapse.
According to
Seidel (2013),
problems of the
aortic valve
causes
abnormal
 murmurs.
Calcium
deposits can
cause a heart
valve such as
mitral valve or
the aortic valve
to become stiff
and narrow. A
calcified valve
may not close
completely,
letting blood flow
backward. The
changes in the
blood flow
creates a
murmur sound.
CENTRAL VESSEL
Carotid Arteries A: (-) bruit sound No bruit sound This indicates a
A: Bruit should be heard normal finding
Jugular veins I: (-) jugular vein Jugular vein Is not This indicates a
I: Distention distention distended normal finding
Peripheral No superficial veins No superficial Veins; Prolonged
Vessels were noted during Good capillary refill capillary refiled
inspection. indicates low
I: presence or Capillary refill 4 cardiac output
appearance of seconds. that leads to
superficial veins, hypoxia. Poor
signs of phlebitis oxygen in the
*Buerger’s Test tissues
*Capillary Refill increases the
 capillary refill
time.
BREAST AND AXILLAE
I: breast for size, Color is same with Breasts vary in size This indicates
symmetry, contour the rest of the body, and are somewhat normal findings
or shape, round and round and
discoloration, pendulous. Smooth pendulous; Color
retraction, and no edema varies depending on
hypervascularity, present on the the client’s skin tone;
swelling, edema breast. Areolas are Texture is smooth
: areola for size, dark brown, with no edema
shape, symmetry, symmetrical, round,
color, surface and without lesions Areolas vary from
characteristics, or masses dark pink to dark
masses, lesions brown; Round and
: nipples for size, Nipples are nearly may vary in size
shape, position equal bilaterally, no
discoloration and Nipples are nearly
discharge present equal bilaterally in
size and are in the
same location in
each breast

P: lymph nodes, No tenderness, Smooth, firm, elastic This indicates

breast, areola & masses, nodules tissue; Breasts normal findings
nipples for and discharges should be a normal
tenderness, palpated over lymph body temperature;
masses, nodules, nodes in breast, No masses palpated
discharge areola, and nipples

ABDOMEN
I: skin integrity, I: Skin conform to Abdominal skin may This indicates a
contour & the color of the be paler than the normal findings
symmetry, hernia, body, no evidence general skin tone; no
distention (girth), of enlargement of evidence of
movements liver or spleen enlargement of liver
associated w/ and spleen. No
respiration, pulsation that may
peristalsis & aortic indicate Abdominal
pulsations aortic aneurysm

MUSCLE
P: tonicity, A score of 5 indicates As per the
flaccidity, full power of muscle strength
spasticity, 3 4
contraction against test, the patient
3
smoothness of gravity and has seen to have
4
movement, resistance or normal a right sided
strength muscle strength, 4 body weakness.
indicates fair but not Reduced nerve
2 5
full strength against input into muscle
gravity and moderate contributes to an
amount of resistance overall reduction
2 5 or slight weakness; 3 in muscle bulk.
indicates just Changes in
sufficient strength to motor function
overcome the force often result in
of gravity or decreased
moderate weakness; strength and
2 indicates the ability agility with
to move but not to increased
overcome the force reaction time.
of gravity or severe Gait is often
weakness; 1 slowed and wide
indicates minimal based. These
contractile power changes can
(weak muscle create difficulties
 contraction can be in maintaining
palpated but no balance.
movement is noted)
or very severe
weakness; and 0
indicates no
movement
NEUROLOGIC
Cranial Nerve - Patient has - Can close Affectation of the
Cranial V decrease eyes, senses cerebral
Cranial Nerve VII corneal reflex the wisp of hemisphere
- Facial cotton against causes the
asymmetry the lower impairment of
was lateral cornea motor area. The
observed to - No facial causes of cranial
the patient. asymmetry neuropathies
Facial noted. Can include stroke
weakness, smile and high blood
and inability symmetrically pressure
to move parts , elevates damages the
of the face both eyebrow, cranial nerves.
symmetricall and frowns Nerve cell
y tightly against cannot
resistance. communicate
with other cells,
and functions
are impaired.
Mental Status - Patient can formulate words properly, but Patient can
- Language noted to have dysarthia. formulate words,
- Orientation - Patient is oriented to month, time, and and have
- Memory date. dysarthia
- Attention Span / - The patient’s memory is still intact, the because of the
Calculation patient is the one who’s giving information impairment in
 to the student nurses, and the relatives the language
Consciousness confirms the statement. dominant
Level Glasgow - The patient participates and willing to cerebral
Coma Scale answer in the interview. hemisphere.
GCS: 15 Impaired
M-6 function of the
V-5 broca’s area
E-4 results to
dysarthia.
Patient’s GCS
score is 15.
6 - For the
motor, the
patient obeys
command, like
“put your right
hands up” – the
patient puts his
hands up with
effort.
5 – the patient is
oriented to time,
person, and
place.
4 – eye
response is
spontaneously.
Even though
there is muscle
weakness in the
area.
RECTUM AND ANUS
I: anus and I: No redness, or I: No redness, or This indicates
surrounding tissue tenderness, skin tenderness, skin normal findings
for color, integrity, intact, wrinkles intact, wrinkles
lesions noted. No noted. No
hemorrhoids noted. hemorrhoids noted.
P: anal sphincter P: no noted P: no noted nodules, This indicates
tonicity, nodules, nodules, masses masses and normal findings.
masses, and and tenderness tenderness noted.
tenderness noted.

C. Gordon’s Functional Pattern of Assessment

Gordon’s Before During Hospitalization Analysis
Assessment Hospitalization
Health The patient The patient stated that, He has maintenance
Perception- stated that “sa “nagsisi nga ako bakit pa medication like
Health tingin ko naman ako kumain ng mga Lanoxin and
Management healthy ako, ganon, sa tingin ko yun enalapril which he
Pattern nagagawa ko yung nagging dahilan always brought
naman yung kung bakit ako whenever he goes
gusto ko. Kaya nakaranas ng ganito. out. With this
nga lagi ko dala Siguro nga hindi ako statement, the
yung mga gamot healthy kaya ngayon patient seems to be
ko sa bag ko sobrang magiingat na cautious with his
para hindi ako ako sa mga ginagawa health, however he
atakihin” ko.” still like to do what
other normal
Her sister The patient is also adolescent do.
verbalized that compliant to his According to Etimoty
“noong 2015 na doctors’/nurses’ orders/ (2021), Denial and
diagnosed sya advice for he wanted to defiant attitudes may
na may sakit sa be well at some point. appear to most
puso. Yun nga adolescent,
rheumatic heart adolescent may feel
daw. Kaya as if they no longer
simula noon, belong or fit in with
every 21 days their peers because
nag pepenicillin of their health
G sya. Mayroon condition.
pa nga syang
notebook, kung Upon observing the
saan nakalagay patient, he seems to
lahat don ng be willing or has
sticker, meron been able to follow
din syang the doctor’s order
regular check up and the nurses’
sa DLSUMC.” advice for his own
good. During
hospitalization he
perceived himself as
unhealthy person
because he had
another
complication which
will make him more
ill and be more
cautious with his
health condition. He
is now compliant to
every doctor’s order
and wants to
improve his lifestyle
after hospitalization.
According to
Galehdar (2021),
adolescent who
stayed in the
 hospital for a long
time, will change
their health
perception. Most
adolescent
understand the
concept of their
disease. They
perceived that it
could lead to death,
and diseases are
inevitable.
Nutritional- The patient The patient stated that Before
Metabolic verbalized “nung mga unang araw hospitalization, he is
Pattern “mahilig ako may nakakabit na tubo fond of eating street
kumain ng saakin, don nilalagay foods, because it
pares, yung pagkain ko, mga 2 satisfies his taste
calamares at weeks siguro akong buds. Even though
kung ano ano ganon.” the patient’s family
pang street buy healthy foods for
foods, paborito The patient’s sister him. He still satisfies
ko ding inumin verbalized that his taste buds by
ay c2” “pagkatapos siya lagyan eating and enjoying
ng NGT nagbago yung street foods.
The patient’s mga kakainin nya, nung According to a study
sister verbalized unam ga lugaw lugaw made by Sanlier
that “sa bahay lang, pero ngayon (2017), although
naman nakakakain siya ng mga consumers know
maraming mga solid foods na mejo that street foods can
masusustansya malalambot. cause contamination
ng with microorganisms
pagkain,nakain and can cause
naman siya pero complications, they
madalas, prefer street foods
natakas siya because of their
para kumain ng cheapness,
pares sa labas” deliciousness,
variety and fast
service. During
hospitalization he is
showing willingness
to reverse the
unhealthy diet to a
healthy lifestyle.
During his first day in
the hospital, he was
placed under
temporary NPO to
prevent the risk of
aspiration. As week
goes by, the doctor
order’s LSLF (NGT)
diet 1800kcal in 6
equally divided
feeding. NGT
insertion was done
to the patient to
prevent aspiration.
As his gag reflex
improves, the doctor
allows the patient to
change his diet to
mechanically soft
diet. Diet as
tolerated with strict
aspiration
 precaution was the
patient’s current
diet. According to
Mahoney (2015),
dysphagia is
common after
stroke, so feeding
through nasogastric
tube may be
necessary.
Elimination The patient “Hindi ko masabi kung Before
Pattern stated that normal ba yung ihi ko hospitalization, the
“normal naman kasi nakadiaper ako, dito patient’s elimination
ung ihi ko, kasi na din ako nadumi, kaso pattern was normal.
nakakaihi di na ko kada umaga Since he doesn’t
naman ako ng nadumi eh. advise din verbalize any signs
maayos sa isang kasi ng doctor ko na mag and symptoms that
araw siguro mga diaper na lang ako.” As will lead to
more than 5 verbalized by the patient. complications.
yung pag ihi ko, However, during
malakas din kasi hospitalization, the
ako uminom ng doctor orders
tubig at c2. Sa complete bedrest
pag dumi without bathroom
naman, tuwing privileges due to his
umaga ako condition that is why
nadumi. Sakto he is wearing diaper.
yun lagi na The doctor
tuwing umaga” prescribed the
patient lactulose 30
cc for the patient to
not strain during
elimination. The
patient should not
exert effort or strain
during elimination.
According to Prieto
(2016), straining
during bowel
movement can
trigger a stroke or
heart attack in the
bathroom. Also, the
patient is
tachycardic with this
straining during
bowel movement
may also aggravate
with his heart
condition. According
to a study made by
Ishiyama et, al.
(2013), strain at
stool causes blood
pressure rise which
can trigger
cardiovascular
events such as
congestive heart
failure, arrhythmia,
acute coronary
disease, and aortic
dissection.
Activity- The patient The patient verbalized, “ Before
Exercise verbalized, ngayong nasa hospital hospitalization, the
Pattern “wala akong ako, limitado na lang patient stays at
masyadong yung mga activities na home playing with
ginagawa sa magagawa ko. Ngayon his phone.
bahay, madalas nga, pati pag punta ko sa Sometimes he
nag ml lang ako CR limitado, naka diaper drives and play
tiktok. Minsan na nga lang ako.” basketball. During
naalis ako, nag this developmental
momotor stage, a normal
kasama mga adolescent would
kaibigan ko like to go and play
panglibang, around with friends
minsan nag and do whatever
babasket ball din they want. Patient
ako.” MPMV, perceived
himself as an
healthy individual
before
hospitalization, that
is why he over do
things. During
hospitalization, the
patient’s activity is
limited. He was
placed under
complete bed rest
without bathroom
privileges. He has
right sided body
weakness, which
also limits his
activity. Pacing him
 on complete bed rest
also prevents the
risk of fall and injury.
According to Gallant
(2017), stroke
patient is left with
residual
impairments such as
reduced mobility,
poor balance, and
decreased muscle
strength making
physical activity
more challenging to
them and which can
lead to accidents.
Rest period should
be planned, and
activities spaced to
give rest between
activities, this is
done to improve
cardiac activity.
Sleep- Rest “mabilis ako “Hirap ako makatulog Due to his condition,
Pattern makatulog, 9 am dito sa hospital, minsan he hasn’t been able
pa lang tilog na maingay eh. Tapos to have an enough
ako tas gigisng pasok pa ng paso kung sleep during his
ako mga 6 or 7” mga nurse lalo sa gabi.” hospitalization,
As verbalized by As verbalized by the reasons may be
the patient. patient. because of hospital
noise, and sometime
“Gumagamit siya ng his sleep is
mga dalawang unan interrupted
tapos nakakatulog siya whenever the nurse
ng matagal sa umaga, checks up on him.
sa gabi naman hirap The patient might be
talaga siyang under stress and
makatulog.” As cannot sleep during
verbalized by the his hospital stay.
patient’s sister. Unfamiliar
environment,
inability to fulfill
roles, worries about
finances, and the
unpredictability of
the disease may
also predispose why
the patient cannot
sleep. The patient
had sleeping
disturbance due to
some noise in the
hospital, which can
be a problem for his
rest and comfortable
environment (Park,
J., 2017). A study
made by Medina
(2019), many people
who are sick have
trouble sleeping and
at some point, they
are having trouble
sleeping because
they are anxious.
The fact that you are
 stress and having
anxiety can cause
sleeping problems.
And based on
observation, he is
using 2 pillows
behind his back
when sleeping
because he is more
comfortable in that
position and thus, it
promotes lung re-
expansion.
Cognitive- “hindi naman The patient’s sister Upon interviewing
Perceptual ako hirap verbalized that “nung the client, we were
Pattern makakita, pati mga unang lingo, di mo able to perform a
pandinig ko okay makausap ng ayos yan physical
eh. Hidni po ako kasi ang tagal nya bago assessment and
nag college, sumagot, pero nasagot assessed his
pero graduate naman sya matagal nga Speech by
po ako ng senior lang at parang hirap observing and
high school magsalita.” listening to the
noong 2019.” patient's
spontaneous
speech. And based
on our observation, it
took him 4 seconds
to respond. Due to
the disease process,
the patient’s left side
brain was damaged,
which damages the
language dominant
in the cerebral
hemisphere that
causes impairment
of the function of
broca’s area that
causes dysarthria to
the patient. .
Sensory speech
area is still intact but
affected a little, that
is why he can
comprehend what
student nurse are
saying. According to
American Stroke
Association,
Dysarthria is a
speech impairment
that sometimes
occurs after a stroke.
It can affect
pronunciation, the
loudness of the
voice and the ability
to speak at a normal
rate with normal
intonation. The
exact speech
problems will differ
from person to
person, depending
on the location and
 severity of the
stroke.
Self- “sa tingin ko The patient verbalized, The patient regrets
Perception/ napag iiwanan “May ibang bagay na not being able to go
Self-Concept na ko,kasi yung kong hindi kayang gawin to college with his
Pattern mga kaibigan ko katulad ng pagbabasket friends. With this the
college na tas ball. Mahilig pa naman patient may lose
ako di na akong magbasketball e self-confidence. The
tumuloy sa pag feeling ko behind na ko patient has a child,
aaral.” As sa mga tropa ko.” and he is thinking for
verbalized by the future of the
the patient. child. If he did not
finish his school his
child may suffer in
the future. In the
other hand, during
hospitalization he
realized that he
cannot do things that
he can before. Due
to his right sided
body weakness,
patient may limit his
activities. According
to a study made by
Saebo (2013),
having a stroke can
change a person’s
life in many ways.
These disabilities
can make returning
to a normal routine
difficult, and for
 many it makes it
impossible for them
to return to normal
routine.
Role The patient “Naghiwalay na sila The patient was still
Relationship verbalized “ako nung mama ng anak living with his
Pattern yung bunso sa 4 niya last year lang, May parents together
na 2021” as verbalized by with his son. Parents
magkakapatid, the patient’s sister. of ill adolescent
meron na rin “Tsaka salitan kami ng tends to take care of
akong anak. 16 mama ko sa their child. In a study
years old pa pagbabantay sakanya made by Saria
lang may aak na ditto sa ospital”, his (2019), parents have
ako. Don ako sister continued. significant
nakatira kela responsibility in the
mama, kasama the patient stated that care of their ill
pa din yung mga “sa ngayon mag fofocus children. Even
kapatid ko pati na lang ako sa anak ko though their child
yung anak ko.” at sa pamilya ko, total di ages, parents still
ko na rin nanman wants to take care of
The patient magagawa yung mga their child.
added “marami nagagawa ko dati, gaya On the other hand,
akong kaibigan, ng pagbabasket ball at the patient has a lot
yung mga pag gala gala ko.” of friends. And
nakakasama ko during
mag motor pati hospitalization, the
mag basketball.” patient loses his self-
esteem, he tends to
say that he will not
be able to do things
before because of
his situation.
According to Richie
 (2017), when
someone has low
self-esteem, they
tend to avoid
situations where
they think there’s
risk of failure. These
can involve school
work, making
friends, and trying
new activities, which
are all important
parts of healthy
teenage life. The
statement of the
patient makes the
student concludes
that, the patient
realizes the
importance of his
child and family.
Sexually The patient He is no longer sexually Patient MPMV is
Reproductiv verbalized that active due to his health single and not
e “nagkaroon ako condition. interested in having
ng ka girlfriend sexual intercourse.
noong 16 years According to Stroke
old ako, tapos Association (2018),
nabuntis ko sya. Hormone
16 ako noon, imbalances can
tapos 18 siya sometimes be due to
noon.” a stroke, leading to a
wide range of
problems including
 difficulty getting an
erection in men or
low sexual desire in
women. This can
happen when a
stroke affects the
parts of your brain
that are important for
controlling
hormones. The high
levels of fatigue
caused by chronic
illness often cause a
low sex drive.
Coping- “Palagi lang The patient verbalized Based on
Stress naman yang “simula nung naospital observation, the
nagkukulong sa ako di ako iniwan ni ate people surrounding
kwarto niya. at mama, salitan pa sila him are paying extra
Lumalabas lang sa pagbabantay sakin, careful to avoid him
kapag kakain.” kaya di ako masyadong from having
As verbalized by naiistress, kasi may stressed out due to
the patient’s nakakausap ako. Atsaka his illness for it may
sister iniisip ko na lang yung become worse. And
anak ko para hindi rin according to his
ako mastress. sister that before he
was
hospitalized/diagnos
ed, he was always at
his room and does
only come out when
he is called to eat his
meal. Which is also
a sign of having a
 life-crisis/problem by
isolating himself
from the
environment and
does not want talk
when asked.
But when he was
hospitalized, there
was an improvement
because he has
been able to
verbalize any
concerns/problems
to his sister who was
his guardian at the
hospital. He then
verbalized a
realization that his
family was always
there for him in every
situation he is stuck
with and knew the
importance of telling
them how grateful he
is to have them as
his family.

Values- Patient Patient stated “hindi ako Upon assessing the

Belief verbalized, katulad nung mga ibang client, he was not
Pattern “hindi naman po nagkakasakit eh, blaming the God for
ako palasimba, merong mga rosary na his illness, for he
pero nag nakasabit. Basta ako was fully aware that
dadasal naman nagdadasal at he himself was the
ako hindi lang po nagpapasalamat na reason why he
obvious. Minsan pinapalakas nya ako sa acquired his illness
nag rorosary araw araw.” by eating unhealthy
kami foods such as
magpapamilya. “Pares” as his
Tsaka hindi favorite. He then
naman ang also verbalized that
diyos ang may despite of not
kasalanan sa having to go to
nangyayari Church every
satin.” Sunday, he still
believes in Him and
always thanking
Him for having a
supportive family
and that he wishes
nothing more but
his family’s health.
Personal Values
are “broad
desirable goals that
motivate people’s
actions and serve
as guiding
principles in their
lives". Everyone
has values, but
each person has a
different value set.
These differences
are affected by an
individual's culture,
personal
upbringing, life
experiences, and a
range of other
influences. Also
most men are not
showy in terms of
their values and
beliefs. According to
a study made by
Roccas S.L (2017),
everyone has
values, but each
person has a
different value set.
These differences
are affected by an
individual's culture,
personal upbringing,
life experiences, and
a range of other
influences. Personal
values are desirable
to an individual and
represent what is
important to
someone.
V. LABORATORY AND DIAGNOSTIC
LABORATORY NORMAL ACTUAL FINDINGS INTERPRETATION
AND FINDINGS
DAGNOSTICS

BLOOD CULTURE AND SENSITIVITY

Bacteriology (-) Negative For Positive for After 24 hours of
Culture Report streptococcus Streptococcus culturing bacteria
Bacteriology viridans. Viridans Species from blood, the
Gram Stain after 24 hours of
results shows (+)
incubation
Gram-positive cocci for Streptococcus
in pairs: 2+ viridans. It indicates
that the bacteria is
still active in the
blood stream, and
this is confirms
Rheumatic heart
disease.
COMPLETE BLOOD COUNT
Hemoglobin 130-180 g/L 107 Hemoglobin
Hematocrit 0.40-0.50 0.33 decreases because
RBC 4.0 x 100^12/L 4.0 of the decrease
blood supply to
other organs which
causes alteration in
the kidney function
which leads to
decrease
production of
erythropoietin. It is
also cause by the
low cardiac output
because it
diminishes the
oxygen supply to
the tissues. With
the decrease
production of
erythropoietin, it
also decreases the
production of RBC
and Hematocrit.
WBC 9.6 x 10^9/L 9.6 This indicates
normal findings.
 DIFFERENTIAL COUNT
Neutrophils 0.55-0.65 prop. 0.81 High amount of
Of 1.0 neutrophils
Lymphocyte 0.25-0.35 prop. 0.14 indicates that there
Of 1.0 is a presence of
microbial
pathogens and
activates
phagocytosis. Low
amount of
lymphocyte
indicates that there
is an infection.
Stabs 0.02-0.05 prop. 0.02 This indicates
Of 1.0 normal findings
Monocyte 0.03-0.06 prop. 0.04 This indicates
Of 1.0 normal findings
Basophil 0.00-0.01 prop. 0.00 This indicates
Of 1.0 normal findings
PROTHROMBIN TIME
PT Patient 12-14.5 seconds 14.3 sec This indicates
normal findings
PT Control 12-14.5 seconds 14.4 sec This indicates
normal findings
INR 0.8-1.3 seconds 1.17 Elevation of INR
indicates that the
blood is taking
longer to clot.
Hence risk for
bleeding. The
patient is taking
aspirin and
clopidogrel which
affects the INR
PARTIAL THROMBOPLASTIN TIME
APTT 24-36 seconds 42.9 The patient is
taking clopidogrel
and aspirin which
prolongs the APTT.
The potent effect
on the final
common pathway
of platelet
aggregation
HEMATOLOGY
Erythrocyte Male below 50 105 Elevated ESR
Sedimentation years old: 0-15 indicates
Rate (ESR) mm/hr inflammation in the
body. Fibrinogen
 and other clotting
proteins and
globulins are
increased thus,
increasing the ESR
BLOOD CHEMESTRY
Potassium 3.5-5.1 mmol/L 3.9 This indicates
normal findings
Creatinine 53.0-106.1 65.90 This indicates
umol/L normal findings
Calcium 2.23-2.50 mmol/L 2.26 This indicates
normal findings
Magnesium 0.66-1.07 mmol/L 0.67 This indicates
normal findings
Blood Urea 2.1-7.1 mmol/L 27.5 This indicates
Nitrogen normal findings
Sodium 136-145 mmol/L 131 Serum sodium is
low because the
blood activates
neurohormonal
system which
prevents the
arterial volume,
and increases
activity of arginine
vasopressin.
Sodium is essential
in regulating blood
volume, blood
pressure and
osmotic equilibrium
and pH.
IMMUNOLOGY
SARS-CoV-2 Negative Negative Negative –
Rapid Antigen indicates
Test absence of
detectable
level of SARS-
Cov -2 Antigen
MRI
 Consider acute to subacute Consider acute to
infarction, left basal ganglia with subacute infarction
extensions and mild mass effect of the basal ganglia
as described. means that there
 Mild sinus inflammatory disease, an embolus caused
both ethmoid and sinuses a blockage in the
 Hyperneumatized sphenoid blood vessel in the
sinuses left basal ganglia
 Based on the MRI
of the patient there
is a mild sinus on
both ethmoid and
maxillary sinus.
This happens due
to inflammation of
paranasal sinus
caused by toxin in
cilla. Mucus
overflows from
sinus.
2D ECHO
 Valvular heart disease Valves in the heart
 Eccentric left ventricular are damaged,
hypertrophy with adequate left which causes valve
disease such as
ventricular systolic function mitral valve
 Dilated left atrium with mildly prolapse, and
elevated left arterial volume index mitral valve
 Anterior mitral valve prolapse with regurgitation. Mild
severe eccentric mitral regurgitant tricuspid
regurgitation was
jet, with vegetation
also seen in the
 Mild tricuspid regurgitation echocardiogram.
Scarring of the
COMPARED WITH PREVIOUS STUDY heart valves
DONE (September 11, 2015); causes the valvular
 Eccentric left ventricular disease.
hypertrophy based on left
ventricular mass index and
relative wall thickness
 Anterior mitral valve prolapse
consider vegetation
 Dilated left atrium with mildly
elevated left atrial volume index
X-RAY
Chest AP View  There are suspicious densities in
the left apex
 The heart is enlarged with a CT
ratio of 0.59

Right Forearm,  There is old healed fracture of the

AP/L views middle 3rd segment of the ulna
with posterolateral angulation
 There is also healed fracture of
the proximal 3rd segment of the
radius with posterior angulation
VI. ANATOMY AND PHYSIOLOGY
ANATOMY OF CARDIOVASCULAR SYSTEM

The cardiovascular system is sometimes called the blood-vascular, or simply the

circulatory, system. It consists of the heart, which is a muscular pumping device, and
a closed system of vessels called arteries, veins, and capillaries. As the name implies,
blood contained in the circulatory system is pumped by the heart around a closed
circle or circuit of vessels as it passes again and again through the various
"circulations" of the body.

FUNCTIONS OF HEART:

1. Managing blood supply. Variations in the rate and force of heart

contraction match blood flow to the changing metabolic needs of the
tissues during rest, exercise, and changes in body position.
2. Producing blood pressure. Contractions of the heart produce blood
pressure, which is needed for blood flow through the blood vessels.
3. Securing one-way blood flow. The valves of the heart secure a one-
way blood flow through the heart and blood vessels.
4. Transmitting blood. The heart separates the pulmonary and systemic
circulations, which ensures the flow of oxygenated blood to tissues.
 The heart wall consists of
three layers enclosed in the
pericardium.

Epicardium - the outer layer of

the wall of the heart and is
formed by the visceral layer of
the serous pericardium.
Myocardium - the muscular
middle layer of the wall of the
heart and has excitable tissue
and the conducting system.
Endocardium. A middle
concentric layer A
subendocardial layer. The rest of the heart is composed mainly of the subepicardial
and subendocardial layers.

CHAMBERS OF THE HEART

The heart has four hollow chambers, or cavities: two atria and two ventricles.

 Receiving chambers. The two superior atria are primarily the receiving
chambers, they play a lighter role in the pumping activity of the heart.
 Discharging chambers. The two inferior, thick-walled ventricles are
the discharging chambers, or actual pumps of the heart wherein when
they contract, blood is propelled out of the heart and into the circulation.
 Septum. The septum that divides the heart longitudinally is referred to
as either the interventricular septum or the interatrial septum,
depending on which chamber it separates.

The heart has four valves. All four valves of the heart have a singular purpose:
allowing forward flow of blood but preventing backward flow. The outflow of each
chamber is guarded by a heart valve:
Atrioventricular valves between the atria and ventricles

1. tricuspid valve (R side of the

heart)
2. mitral valve/bicuspid valve
(left side of the heart)
Semilunar valves which are located in the
outflow tracts of the ventricles

1. aortic valve (L side heart)

2. pulmonary valve (R side
heart)

BLOOD SUPPLY

The heart is supplied by two coronary arteries: Left main coronary artery carries
80% of the flow to the heart muscle. It is a short artery that divides into two branches
Left anterior descending artery that supplies anterior two-thirds of the inter-ventricular
septum and adjoining part of the left ventricular anterior wall Circumflex coronary
artery that supplies blood to the lateral and posterior portions of the left ventricle. 2.
Right coronary artery: branches supply the right ventricle, right atrium, and left
ventricle's inferior wall. Coronary arteries and veins course over the surface of the
heart. Most coronary veins coalesce into the coronary sinus that runs in the left
posterior atrioventricular groove and opens into the right atrium. Other small veins,
called thebesian veins, open directly into all four chambers of the heart. Image:
Overview of the coronary arteries and cardiac veins - anterior and posterior views.
NERVES SUPPLY

The main control of the heart resides with the

medulla oblongata. There is an area called the
cardioacceleratory centre, or pressor centre, in
the upper part of the medulla oblongata, and an
area called the cardioinhibitory centre, or
depressor centre, in the lower part. Together they
are called the cardioregulatory centre, since they
interact to control heart rate, etc. The nervous
supply to the heart is autonomic, consisting of
both sympathetic and parasympathetic parts. The
sympathetic fibres arise from the pressor centre,
while the parasympathetic fibres arise in the
depressor center. See also Vagal Tone The
sympathetic nervous system acts on the
sinoatrial node, speeding up the depolarization
rate, and therefore increasing the heart rate. The
parasympathetic system works in reverse in order
to slow the heart rate down. The heart itself has a natural pacemaker, the
sinoatrial node, which does not need a nervous supply to function. If you sever
all the nerves to the heart, then it will continue to beat. In fact, it will beat faster
than normal, since there is normally a parasympathetic supply slowing the heart
down.
  Tunica intima. The
tunica intima, which lines the
lumen, or interior, of the
vessels, is a thin layer of
endothelium resting on a
basement membrane and
decreases friction as blood
flows through the vessel
lumen.
 Tunica media. The
tunica media is the bulky
middle coat which mostly
consists of smooth muscle and
elastic fibers that constrict or
dilate, making the blood pressure increase or decrease.
 Tunica externa. The tunica externa is the outermost tunic composed largely of
fibrous connective tissue, and its function is basically to support and protect the
vessels.

3 TYPES OF BLOOD VESSELS

 Arteries: These are elastic vessels that transport blood away from the
heart. Pulmonary arteries carry blood from the heart to the lungs where oxygen
is picked up by red blood cells. Systemic arteries deliver blood to the rest of the
body.
 Veins: These are also elastic vessels but they transport blood to the heart. The
four types of veins are pulmonary, systemic, superficial, and deep veins.
 Capillaries: These are extremely small vessels located within the tissues of the
body that transport blood from the arteries to the veins. Fluid and gas exchange
between capillaries and body tissues takes place at capillary beds.
 Arterial Branches of the
Ascending Aorta

The aorta springs upward from the

left ventricle of heart as the
ascending aorta.

 Coronary arteries. The only

branches of the ascending aorta are
the right and left coronary arteries,
which serve the heart.
Arterial Branches of the Aortic
Arch

The aorta arches to the left as the

aortic arch.

 Brachiocephalic trunk. The brachiocephalic trunk, the first branch off

the aortic arch, splits into the right common carotid artery and right
subclavian artery.
 Left common carotid artery. The left common carotid artery is the
second branch off the aortic arch and it divides, forming the left internal
carotid, which serves the brain, and the left external carotid, which
serves the skin and muscles of the head and neck.
 Left subclavian artery. The third branch of the aortic arch, the left
subclavian artery, gives off an important branch- the vertebral artery,
which serves part of the brain.
 Axillary artery. In the axilla, the subclavian artery becomes the axillary
artery.
 Brachial artery. the subclavian artery continues into the arm as the
brachial artery, which supplies the arm.
 Radial and ulnar arteries. At the elbow, the brachial artery splits to form
the radial and ulnar arteries, which serve the forearm.

PHYSIOLOGY OF THE HEART

An electrical conduction
system regulates the
pumping of the heart and
timing of contraction of
various chambers. Heart
muscle contracts in
response to the electrical
stimulus received system
generates electrical
impulses and conducts
them throughout the
muscle of the heart, stimulating the heart to contract and pump blood.
Among the major elements in the cardiac conduction system are the
sinus node, atrioventricular node, and the autonomic nervous system.
 Cardiac muscle cells. Cardiac muscle cells can and do contract
spontaneously and independently, even if all nervous connections are
severed.
 Rhythms. Although cardiac muscles can beat independently, the
muscle cells in the different areas of the heart have different rhythms.
 Intrinsic conduction system. The intrinsic conduction system, or
the nodal system, that is built into the heart tissue sets the basic rhythm.
 Composition. The intrinsic conduction system is composed of a special
tissue found nowhere else in the body; it is much like a cross between a
muscle and nervous tissue.
 Function. This system causes heart muscle depolarization in only one
direction- from the atria to the ventricles; it enforces a contraction rate of
 approximately 75 beats per minute on the heart, thus the heart beats as
a coordinated unit.
 Sinoatrial (SA) node. The SA node has the highest rate of
depolarization in the whole system, so it can start the beat and set the
pace for the whole heart; thus the term “pacemaker“.
 Atrial contraction. From the SA node, the impulse spread through the
atria to the AV node, and then the atria contract.
 Ventricular contraction. It then passes through the AV bundle, the
bundle branches, and the Purkinje fibers, resulting in
a “wringing” contraction of the ventricles that begins at the heart apex
and moves toward the atria.
 Ejection. This contraction effectively ejects blood superiorly into the
large arteries leaving the heart.

PATHWAY OF CONDUCTION SYSTEM

The conduction system occurs systematically through:

 SA node. The depolarization wave is initiated by the sinoatrial node.

 Atrial myocardium. The wave then successively passes through the
atrial myocardium.
 Atrioventricular node. The depolarization wave then spreads to the AV
node, and then the atria contract.
 AV bundle. It then passes rapidly through the AV bundle.
 Bundle branches and Purkinje fibers. The wave then continues on
through the right and left bundle branches, and then to the Purkinje fibers
in the ventricular walls, resulting in a contraction that ejects blood,
leaving the heart.

CARDIAC CYCLE AND HEART SOUNDS

In a healthy heart, the atria contract simultaneously, then, as they start to relax,
contraction of the ventricles begin.

 Systole. Systole means heart contraction.

 Diastole. Diastole means heart relaxation.
 Cardiac cycle. The term cardiac cycle refers to the events of one
complete heart beat, during which both atria and ventricles contract and
then relax.
 Length. The average heart beats approximately 75 times per minute, so
the length of the cardiac cycle is normally about 0.8 second.
 Mid-to-late diastole. The cycle starts with the heart in
complete relaxation; the pressure in the heart is low, and blood is
flowing passively into and through the atria into the ventricles from the
pulmonary and systemic circulations; the semilunar valves are closed,
and the AV valves are open; then the atria contract and force the blood
remaining in their chambers into the ventricles.
 Ventricular systole. Shortly after, the ventricular contraction begins,
and the pressure within the ventricles increases rapidly, closing the AV
valves; when the intraventricular pressure is higher than the pressure
in the large arteries leaving the heart, the semilunar valves are forced
open, and blood rushes through them out of the ventricles; the atria are
relaxed, and their chambers are again filling with blood.
 Early diastole. At the end of systole, the ventricles relax, the semilunar
valves snap shut, and for a moment the ventricles are completely closed
chambers; the intraventricular pressure drops and the AV valves are
forced open; the ventricles again begin refilling rapidly with blood,
completing the cycle.
 First heart sound. The first heart sound, “lub”, is caused by the closing
of the AV valves.
 Second heart sound. The second heart sound, “dub”, occurs when
the semilunar valves close at the end of systole.

CARDIAC OUTPUT
Cardiac output is the amount of blood pumped out by each side of the heart in one
minute. It is the product of the heart rate and the stroke volume.

 Stroke volume. Stroke volume is the volume of blood pumped out by a

ventricle with each heartbeat.
 Regulation of stroke volume. According to Starling’s law of the
heart, the critical factor controlling stroke volume is how much the
cardiac muscle cells are stretched just before they contract; the more
they are stretched, the stronger the contraction will be; and anything
that increases the volume or speed of venous return also increases
stroke volume and force of contraction.
 Factors modifying basic heart rate.The most important external
influence on heart rate is the activity of the autonomic nervous
system, as well as physical factors (age, gender, exercise, and body
temperature).

BLOOD CIRCULATION THROUGH THE HEART

 Entrance to the heart. Blood enters

the heart through two large veins, the inferior
and superior vena cava, emptying oxygen-
poor blood from the body into the right atrium
of the heart.
 Atrial contraction. As the atrium
contracts, blood flows from the right atrium to
the right ventricle through the open tricuspid
valve.
 Closure of the tricuspid
valve. When the ventricle is full, the tricuspid valve shuts to prevent
blood from flowing backward into the atria while the ventricle contracts.
 Ventricle contraction. As the ventricle contracts, blood leaves the heart
through the pulmonic valve, into the pulmonary artery and to the lungs
where it is oxygenated.
  Oxygen-rich blood circulates. The pulmonary vein empties oxygen-
rich blood from the lungs into the left atrium of the heart.
 Opening of the mitral valve. As the atrium contracts, blood flows from
your left atrium into your left ventricle through the open mitral valve.
 Prevention of backflow. When the ventricle is full, the mitral valve
shuts. This prevents blood from flowing backward into the atrium while
the ventricle contracts.
 Blood flow to systemic circulation. As the ventricle contracts, blood
leaves the heart through the aortic valve, into the aorta and to the body.
STROKE VOLUME

Stroke volume (SV) is the volume of blood pumped from the left ventricle per beat.
Stroke volume is calculated using measurements of ventricle volumes from
an echocardiogram and subtracting the volume of the blood in the ventricle at the end
of a beat (called end-systolic volume) from the volume of blood just prior to the beat
(called end-diastolic volume). The term stroke volume can apply to each of the two
ventricles of the heart, although it usually refers to the left ventricle. The stroke
volumes for each ventricle are generally equal, both being approximately 70 mL in a
healthy 70-kg man.

Stroke volume is an important determinant of cardiac output, which is the product of

stroke volume and heart rate, and is also used to calculate ejection fraction, which is
stroke volume divided by end-diastolic volume. Because stroke volume decreases in
certain conditions and disease states, stroke volume itself correlates with cardiac
function.

PRELOAD AND AFTERLOAD

There are two determinants of cardiac output – preload and afterload. Here's more
about these determinants.
 Preload

Preload is basically the stretch on the

sarcomeres just before your heart
contracts (systoles). The sarcomeres will
stretch more if there is more blood in the
chamber just before contraction. When
sarcomeres are stretched further, the
contraction will be equally strong. This
will increase the stroke volume. If you ask the relationship between the strength of
contraction and end-diastolic sarcomere length, there are two basic explanations.
Initially, there is a greater chance for actin-myosin cross bridging; another
explanation is that this happens because length dependent channels become
activated in the process.

Afterload

Afterload refers to the stress or tension generated by the left ventricle wall during
ejection of blood. Besides, the state of your blood vessels plays a big role in this
process. Your blood vessels have the ability to dilate and constrict, which in turn
help change the total resistance to blood flow. Afterload will get affected by this
resistance. An important thing to understand is that your heart doesn't usually eject
all blood it has, but ejects only 2/3 of the total blood available in its chamber at end-
diastole. With an increase in afterload, not enough blood in the ventricle would
move out. When afterload decreases, it allows more blood to leave the chamber.
It implies that with an increase in afterload, stroke volume will decrease and vice
versa.

ANATOMY OF NERVOUS SYSTEM

The nervous system is a complex network of nerves and nerve cells (neurons) that
carry signals or messages to and from the brain and spinal cord to different parts of
the body. It is made up of the central nervous system and the peripheral nervous
system.

Nervous system can be

divided into two major
regions:

 Central
 Peripheral Nervous
Systems

The central nervous

system (CNS) is made up of
the brain and spinal cord.
The brain controls most body
functions, including
awareness, movements, sensations, thoughts, speech and memory. The spinal cord
is connected to the brain at the brain stem and is covered by the vertebrae of the spine.
Nerves exit the spinal cord to both sides of the body. The spinal cord carries signals
back and forth between the brain and the nerves in the rest of the body.

The peripheral nervous system (PNS) is the part of the nervous system outside of
the CNS. It is made up of nerves and ganglia that send signals to and receive signals
from the CNS.

Peripheral nervous system is divided into two:

 Somatic Nervous System: The somatic nervous system controls body

movements that are under our control such as walking. The autonomic nervous
system controls involuntary functions that the body does on its own such as
breathing and digestion.
 Autonomic Nervous System: The autonomic nervous system controls
involuntary functions that the body does on its own such as breathing and
digestion. a visceral
efferent system, which
means it sends motor
impulses to the visceral
organs. It functions
automatically and
continuously, without
conscious effort, to
innervate smooth
muscle, cardiac muscle,
and glands. It is concerned
with heart rate, breathing
rate, blood pressure, body
temperature, and other visceral activities that work together to
maintain homeostasis.

Autonomic nervous system is

further divided into two:

 Sympathetic Nervous
Systems: The sympathetic
nervous system prepares the
body for situations that require
strength and heightened
awareness or situations that
arouse fear, anger, excitement
or embarrassment. This is
called the fight-or-flight
response. It causes the heart to
beat faster, makes you breathe quicker and more shallowly, dilates the pupils
and increases metabolism.
  Parasympathetic Nervous Systems: The parasympathetic nervous system has
a calming effect on the body. It returns heart rate and breathing to normal,
constricts the pupils and slows down metabolism to conserve energy.

NEURONS

Neurons, also called nerve cells,

are highly specialized to transmit
messages (nerve impulses) from
one part of the body to another.

 Cell body. The cell body is the

metabolic center of the neuron; it
has a transparent nucleus with a
conspicuous nucleolus; the rough
ER, called Nissl substance,
and neurofibrils are particularly
abundant in the cell body.
 Processes. The armlike processes, or fibers, vary in length from microscopic
to 3 to 4 feet; dendrons convey incoming messages toward the cell body,
while axons generate nerve impulses and typically conduct them away from
the cell body.
 Axon hillock. Neurons may have hundreds of the branching dendrites,
depending on the neuron type, but each neuron has only one axon, which
arises from a conelike region of the cell body called the axon hillock.
 Axon terminals.These terminals contain hundreds of tiny vesicles, or
membranous sacs that contain neurotransmitters.
 Synaptic cleft. Each axon terminal is separated from the next neuron by a tiny
gap called synaptic cleft.
 Myelin sheaths. Most long nerve fibers are covered with a whitish, fatty
material called myelin, which has a waxy appearance; myelin protects and
insulates the fibers and increases the transmission rate of nerve impulses.
 Nodes of Ranvier. Because the myelin sheath is formed by many individual
Schwann cells, it has gaps, or indentations, called nodes of Ranvier.
 CLASSIFICATION

Neurons may be classified either

according to how they function or
according to their structure.

 Functional
classification. Functional
classification groups neurons
according to the direction the nerve impulse is traveling relative to the CNS; on
this basis, there are sensory, motor, and association neurons.

 Sensory neurons. Neurons carrying impulses from sensory receptors to the

CNS are sensory, or afferent, neurons; sensory neurons keep us informed
about what is happening both inside and outside the body.
 Motor neurons. Neurons carrying impulses from the CNS to the viscera and/or
muscles and glands are motor, or efferent, neurons.
 Interneurons. The third category of neurons is known as the interneurons,
or association neurons; they connect the motor and sensory neurons in neural
pathways.
 Structural classification. Structural classification is based on the number of
processes extending from the cell body.
 Multipolar neuron. If there are several processes, the neuron is a multipolar
neuron; because all motor and association neurons are multipolar, this is the
most common structural type.
 Bipolar neurons. Neurons with two processes- an axon and a dendrite- are
called bipolar neurons; these are rare in adults, found only in some special
sense organs, where they act in sensory processing as receptor cells.
 Unipolar neurons. Unipolar neurons have a single process emerging from the
cell’s body, however, it is very short and divides almost immediately into
proximal (central) and distal (peripheral) processes.
 Central Nervous System
During embryonic
development, the CNS first
appears as a simple tube,
the neural tube, which
extends down the dorsal
median plan of the
developing embryo’s body.

BRAIN

Brain is the largest and

most complex mass of nervous tissue in the body, it is commonly discussed in terms
of its four major regions:

 Cerebral hemispheres
 Diencephalon
 Brain stem
 Cerebellum

Cerebral Hemisphere

The paired cerebral hemispheres, collectively called cerebrum, are the most superior
part of the brain, and together are a good deal larger than the other three brain regions
combined.

 Gyri. The entire surface of the cerebral hemispheres exhibits elevated ridges
of tissue called gyri, separated by shallow grooves called sulci.
 Fissures. Less numerous are the deeper grooves of tissue called fissures,
which separate large regions of the brain; the cerebral hemispheres are
separated by a single deep fissure, the longitudinal fissure.
 Lobes. Other fissures or sulci divide each hemisphere into a number of lobes,
named for the cranial bones that lie over them.
 Regions of cerebral hemisphere. Each cerebral hemisphere has three basic
regions: a superficial cortex of gray matter, an internal white matter, and
the basal nuclei.
  Cerebral cortex. Speech, memory, logical and emotional response, as well as
consciousness, interpretation of sensation, and voluntary movement are all
functions of neurons of the cerebral cortex.
 Parietal lobe. The primary somatic sensory area is located in the parietal
lobe posterior to the central sulcus; impulses traveling from the body’s sensory
receptors are localized and interpreted in this area.
 Occipital lobe. The visual area is located in the posterior part of the occipital
lobe.
 Temporal lobe. The auditory area is in the temporal lobe bordering
the lateral sulcus, and the olfactory area is found deep inside the temporal
lobe.
 Frontal lobe. The primary motor area, which allows us to consciously move
our skeletal muscles, is anterior to the central sulcus in the front lobe.
 Pyramidal tract. The axons of these motor neurons form the major voluntary
motor tract- the corticospinal or pyramidal tract, which descends to the cord.
 Broca’s area. A specialized cortical area that is very involved in our ability to
speak, Broca’s area, is found at the base of the precentral gyrus (the gyrus
anterior to the central sulcus).
 Speech area. The speech area is located at the junction of the temporal,
parietal, and occipital lobes; the speech area allows one to sound out words.
 Cerebral white matter. The deeper cerebral white matter is compose of fiber
tracts carrying impulses to, from, and within the cortex.
 Corpus callosum. One very large fiber tract, the corpus callosum, connect the
cerbral hemispheres; such fiber tracts are called commisures.
 Fiber tracts. Association fiber tracts connect areas within a hemisphere,
and projection fiber tracts connect the cerebrum with lower CNS centers.
 Basal nuclei. There are several islands of gray matter, called the basal nuclei,
or basal ganglia, buried deep within the white matter of the cerebral
hemispheres; it helps regulate the voluntary motor activities by modifying
instructions sent to the skeletal muscles by the primary motor cortex.

DIENCEPHALON
The diencephalon, or interbrain, sits atop the brain stem and is enclosed by the
cerebral hemispheres.
  Thalamus. The thalamus, which encloses the shallow third ventricle of the
brain, is a relay station for sensory impulses passing upward to the sensory
cortex.
 Hypothalamus. The hypothalamus makes up the floor of the diencephalon; it
is an important autonomic nervous system center because it plays a role in the
regulation of body temperature, water balance, and metabolism; it is also the
center for many drives and emotions, and as such, it is an important part of the
so-called limbic system or “emotional-visceral brain”; the hypothalamus also
regulates the pituitary gland and produces two hormones of its own.
 Mammillary bodies. The mammillary bodies, reflex centers involved in
olfaction (the sense of smell), bulge from the floor of the hypothalamus posterior
to the pituitary gland.
 Epithalamus. The epithalamus forms the roof of the third ventricle; important
parts of the epithalamus are the pineal body (part of the endocrine system)
and the choroid plexus of the third ventricle, which forms the cerebrospinal
fluid.

BRAIN STEM
The brain stem is about the size of a thumb in diameter and approximately 3 inches
long.

 Structures. Its structures are the midbrain, pons, and the medulla
oblongata.
 Midbrain. The midbrain extends from the mammillary bodies to the pons
inferiorly; it is composed of two bulging fiber tracts, the cerebral peduncles,
which convey descending and ascending impulses.
 Corpora quadrigemina. Dorsally located are four rounded protrusions called
the corpora quadrigemina because they remind some anatomist of two pairs of
twins; these bulging nuclei are reflex centers involved in vision and hearing.
 Pons. The pons is a rounded structure that protrudes just below the midbrain,
and this area of the brain stem is mostly fiber tracts; however, it does have
important nuclei involved in the control of breathing.
 Medulla oblongata. The medulla oblongata is the most inferior part of the brain
stem; it contains nuclei that regulate vital visceral activities; it contains centers
 that control heart rate, blood pressure, breathing, swallowing,
and vomiting among others.
 Reticular formation. Extending the entire length of the brain stem is a diffuse
mass of gray matter, the reticular formation; the neurons of the reticular
formation are involved in motor control of the visceral organs; a special group
of reticular formation neurons, the reticular activating system (RAS), plays a
role in consciousness and the awake/sleep cycles.

CEREBELLUM
The large, cauliflower-like cerebellum projects dorsally from under the occipital lobe of
the cerebrum.

 Structure. Like the cerebrum. the cerebellum has two hemispheres and a
convoluted surface; it also has an outer cortex made up of gray matter and an
inner region of white matter.
 Function. The cerebellum provides precise timing for skeletal muscle activity
and controls our balance and equilibrium.
 Coverage. Fibers reach the cerebellum from the equilibrium apparatus of the
inner ear, the eye, the proprioceptors of the skeletal muscles and tendons, and
many other areas.

PROTECTION OF THE CENTRAL NERVOUS SYSTEM

Nervous tissue is very soft and delicate, and the irreplaceable neurons are injured by
even the slightest pressure, so nature has tried to protect the brain and the spinal
cord by enclosing them within bone (the skull and vertebral column), membranes
(the meninges), and a watery cushion (cerebrospinal fluid).

MENINGES
The three connective tissue membranes covering and protecting the CNS structures
are the meninges.

 Dura mater. The outermost layer,

the leathery dura mater, is a double
layered membrane where it surrounds
the brain; one of its layer is attached to
the inner surface of the skull, forming
the periosteum (periosteal layer); the
other, called the meningeal layer, forms
the outermost covering of the brain and continues as the dura mater of the
spinal cord.
 Falx cerebri. In several places, the inner dural membrane extends inward to
form a fold that attaches the brain to the cranial cavity, and one of these folds
is the falx cerebri.
 Tentorium cerebelli. The tentorium cereberi separates the cerebellum from
the cerebrum.
 Arachnoid mater. The middle layer is the weblike arachnoid mater; its
threadlike extensions span the subarachnoid space to attach it to the
innermost membrane.
 Pia mater. The delicate pia mater, the innermost meningeal layer, clings
tightly to the surface of the brain and spinal cord, following every fold.

CEREBROSPINAL FLUID
Cerebrospinal fluid (CSF) is a watery “broth” similar in its makeup to blood plasma,
from which it forms.

 Contents. The CSF contains less protein and more vitamin C, and glucose.
 Choroid plexus. CSF is continually formed from blood by the choroid plexuses;
choroid plexuses are clusters of capillaries hanging from the “roof” in each of
the brain’s ventricles.
 Function. The CSF in and around the brain and cord forms a watery cushion
that protects the fragile nervous tissue from blows and other trauma.
  Normal volume. CSF forms and drains at a constant rate so that its normal
pressure and volume (150 ml-about half a cup) are maintained.
 Lumbar tap. The CSF sample for testing is obtained by a procedure called
lumbar or spinal tap because the withdrawal of fluid for testing decreases CSF
fluid pressure, the patient must remain in a horizontal position (lying down) for
6 to 12 hours after the procedure to prevent an agonizingly painful “spinal
headache”.
The Blood-Brain Barrier

No other body organ is so absolutely dependent on a constant internal environment

as is the brain, and so the blood-brain barrier is there to protect it.

 Function. The neurons are kept separated from bloodborne substances by the
so-called blood-brain barrier, composed of the least permeable capillaries in
the whole body.
 Substances allowed. Of water-soluble substances, only water, glucose, and
essential amino acids pass easily through the walls of these capillaries.
 Prohibited substances. Metabolic wastes, such as toxins, urea, proteins, and
most drugs are prevented from entering the brain tissue.
 Fat-soluble substances. The blood-brain barrier is virtually useless against
fats, respiratory gases, and other fat-soluble molecules that diffuse easily
through all plasma membranes.

SPINAL CORD
The cylindrical spinal cord is a glistening white continuation of the brain stem.

 Length. The spinal cord is approximately 17

inches (42 cm) long.
 Major function. The spinal cord provides a
two-way conduction pathway to and from the
brain, and it is a major reflex center (spinal
reflexes are completed at this level).
 Location. Enclosed within the vertebral
column, the spinal cord extends from the
foramen magnum of the skull to the first or
second lumbar vertebra, where it ends just
below the ribs.
 Meninges. Like the brain, the spinal cord is cushioned and protected by the
meninges; meningeal coverings do not end at the second lumbar vertebra but
instead extend well beyond the end of the spinal cord in the vertebral canal.
 Spinal nerves. In humans, 31 pairs of spinal nerves arise from the cord and
exit from the vertebral column to serve the body area close by.
 Cauda equina. The collection of spinal nerves at the inferior end of the
vertebral canal is called cauda equina because it looks so much like a horse’s
tail.

GRAY MATTER OF THE SPINAL CORD AND SPINAL ROOTS

The gray matter of the spinal cord looks like a butterfly or a letter H in cross section.

 Projections. The two posterior projections are the dorsal, or posterior, horns;
the two anterior projections are the ventral, or anterior, horns.
 Central canal. The gray matter surrounds the central canal of the cord, which
contains CSF.
 Dorsal root ganglion. The cell bodies of sensory neurons, whose fibers enter
the cord by the dorsal root, are found in an enlarged area called dorsal root
ganglion; if the dorsal root or its ganglion is damaged, sensation from the body
area served will be lost.
  Dorsal horns. The dorsal horns contain interneurons.
 Ventral horns. The ventral horns of gray matter contain cell bodies of motor
neurons of the somatic nervous system, which send their axons out the ventral
root of the cord.
 Spinal nerves. The dorsal and ventral roots fuse to form the spinal nerves.

WHITE MATTER OF THE SPINAL CORD

White matter of the spinal cord is composed of myelinated fiber tracts- some running
to higher centers, some traveling from the brain to the cord, and some conducting
impulses from one side of the spinal cord to the other.

 Regions. Because of the irregular shape of the gray matter, the white matter
on each side of the cord is divided into three regions- the dorsal, lateral,
and ventral columns; each of the columns contains a number of fiber tracts
made up of axon with the same destination and function.
 Sensory tracts. Tracts conducting sensory impulses to the brain are sensory,
or afferent, tracts.
 Motor tracts. Those carrying impulses from the brain to skeletal muscles are
motor, or efferent, tracts.
Peripheral Nervous System
The peripheral nervous system consists of nerves and scattered groups of neuronal
cell bodies (ganglia) found outside the CNS

Structure of a Nerve

A nerve is a bundle of neuron fibers found outside the CNS.

 Endoneurium. Each fiber is surrounded by a delicate connective tissue

sheath, an endoneurium.
 Perimeurium. Groups of fibers are bound by a coarser connective tissue
wrapping, the perineurium, to form fiber bundles, or fascicles.
 Epineurium. Finally, all the fascicles are bound together by a tough fibrous
sheath, the epineurium, to form the cordlike nerve.
  Mixed nerves. Nerves carrying both sensory and motor fibers are called
mixed nerves.
 Sensory nerves. Nerves that carry impulses toward the CNS only are called
sensory, or afferent, nerves.
 Motor nerves. Those that carry only motor fibers are motor, or efferent,
nerves.

CRANIAL NERVES

The 12 pairs of cranial nerves primarily serve the head and the neck.
 Olfactory. Fibers arise from the olfactory receptors in the nasal mucosa and
synapse with the olfactory bulbs; its function is purely sensory, and it carries
impulses for the sense of smell.
 Optic. Fibers arise from the retina of the eye and form the optic nerve; its
function is purely sensory, and carries impulses for vision.
 Oculomotor. Fibers run from the midbrain to the eye; it supplies motor fibers
to four of the six muscles (superior, inferior, and medial rectus, and inferior
oblique) that direct the eyeball; to the eyelid; and to the internal eye muscles
controlling lens shape and pupil size.
 Trochlear. Fibers run from the midbrain to the eye; it supplies motor fibers for
one external eye muscle ( superior oblique).
 Trigeminal. Fibers emerge from the pons and form three divisions that run to
the face; it conducts sensory impulses from the skin of the face and mucosa of
the nose and mouth; also contains motor fibers that activate the chewing
muscles.
 Abducens. Fibers leave the pons and run to the eye; it supplies motor fibers to
the lateral rectus muscle, which rolls the eye laterally.
 Facial. Fibers leave the pons and run to the face; it activates the muscles of
facial expression and the lacrimal and salivary glands; carries sensory impulses
from the taste buds of the anterior tongue.
 Vestibulocochlear. fibers run from the equilibrium and hearing receptors of the
inner ear to the brain stem; its function is purely sensory; vestibular branch
transmits impulses for the sense of balance, and cochlear branch transmits
impulses for the sense of hearing.
 Glossopharyngeal. Fibers emerge from the medulla and run to the throat; it
supplies motor fibers to the pharynx (throat) that promote swallowing and saliva
production; it carries sensory impulses from the taste buds of the posterior
tongue and from pressure receptors of the carotid artery.
 Vagus. Fibers emerge from the medulla and descend into the thorax and
abdominal cavity; the fibers carry sensory impulses from and motor impulses
to the pharynx, larynx, and the abdominal and thoracic viscera; most motor
fibers are parasympathetic fibers that promote digestive activity and help
regulate heart activity.
  Accessory. Fiber arise from the medulla and superior spinal cord and travel to
muscles of the neck and back; mostly motor fiber that activate the
sternocleidomastoid and trapezius muscles.
 Hypoglossal. Fibers run from the medulla to the tongue; motor fibers control
tongue movements;; sensory fibers carry impulses from the tongue.

SPINAL NERVES AND NERVE PLEXUSES

The 31 pairs of human spinal nerves are formed by the combination of the ventral and
dorsal roots of the spinal cord.

 Rami. Almost immediately after being formed, each spinal nerve divides into
dorsal and ventral rami, making each spinal nerve only about 1/2 inch long; the
rami contains both sensory and motor fibers.
 Dorsal rami. The smaller dorsal rami serve the skin and muscles of the
posterior body trunk.
 Ventral rami. The ventral rami of spinal nerves T1 through T12 form the
intercostal nerves, which supply the muscles between the ribs and the skin and
muscles of the anterior and lateral trunk.
 Cervical plexus. The cervical plexus originates from the C1-C5, and phrenic
nerve is an important nerve; it serves the diaphragm, and skin and muscles of
the shoulder and neck.
 Brachial plexus. The axillary nerve serve the deltoid muscles and skin of the
shoulder, muscles, and skin of superior thorax; the radial nerve serves the
triceps and extensor muscles of the forearm, and the skin of the posterior upper
limb; the median nerve serves the flexor muscles and skin of the forearm and
some muscles of the hand; the musculocutaneous nerve serves the flexor
muscles of arm and the skin of the lateral forearm; and the ulnar nerve serves
some flexor muscles of forearm; wrist and many hand muscles, and the skin of
the hand.
 Lumbar plexus. The femoral nerve serves the lower abdomen, anterior and
medial thigh muscles, and the skin of the anteromedial leg and thigh;
the obturator nerve serves the adductor muscles of the medial thigh and small
hip muscles, and the skin of the medial thigh and hip joint.
  Sacral plexus. The sciatic nerve (largest nerve in the body) serves the lower
trunk and posterior surface of the thigh, and it splits into the common fibular
and tibial nerves; the common fibular nerve serves the lateral aspect of the
leg and foot, while the tibial nerve serves the posterior aspect of leg and foot;
the superior and inferior gluteal nerves serve the gluteal muscles of the hip.

AUTONOMIC NERVOUS SYSTEM

The autonomic nervous system (ANS) is the motor subdivision of the PNS that controls
body activities automatically.

 Composition. It is composed of a specialized group of neurons that regulate

cardiac muscle, smooth muscles, and glands.
 Function. At every moment, signals flood from the visceral organs into the
CNS, and the automatic nerves make adjustments as necessary to best support
body activities.
 Divisions. The ANS has two arms: the sympathetic division and the
parasympathetic division.

ANATOMY OF THE PARASYMPATHETIC DIVISION

The parasympathetic division allows us to “unwind” and conserve energy.

 Preganglionic neurons. The preganglionic neurons of the parasympathetic

division are located in brain nuclei of several cranial nerves- III, VII, IX, and X
(the vagus being the most important of these) and in the S2 through S4 levels
of the spinal cord.
 Craniosacral division. The parasympathetic division is also called the
craniosacral division; the neurons of the cranial region send their axons out in
cranial nerves to serve the head and neck organs.
 Pelvic splanchnic nerves. In the sacral region, the preganglionic axons leave
the spinal cord and form the pelvic splanchnic nerves, also called the pelvic
nerves, which travel to the pelvic cavity.

ANATOMY OF THE SYMPATHETIC DIVISION

The sympathetic division mobilizes the body during extreme situations, and is also
called the thoracolumbar division because its preganglionic neurons are in the gray
matter of the spinal cord from T1 through L2.

 Ramus communicans. The preganglionic axons leave the cord in the ventral
root, enter the spinal nerve, and then pass through a ramus communicans, or
small communicating branch, to enter a sympathetic chain ganglion.
 Sympathetic chain. The sympathetic trunk, or chain, lies along the vertebral
column on each side.
 Splanchnic nerves. After it reaches the ganglion, the axon may synapse with
the second neuron in the sympathetic chain at the same or a different level, or
the axon may through the ganglion without synapsing and form part of the
splanchnic nerves.
 Collateral ganglion. The splanchnic nerves travel to the viscera to synapse
with the ganglionic neuron, found in a collateral ganglion anterior to the
vertebral column.

PHYSIOLOGY OF THE NERVOUS SYSTEM

The physiology of the nervous system involves a complex journey of impulses.

NERVE IMPULSE
Neurons have two major functional properties: irritability, the ability to respond to a
stimulus and convert it into a nerve impulse, and conductivity, the ability to transmit
the impulse to other neurons, muscles, or glands.
 Electrical conditions of a resting neuron’s membrane. The plasma
membrane of a resting, or inactive, neuron is polarized, which means that there
are fewer positive ions sitting on the inner face of the neuron’s plasma
membrane than there are on its outer surface; as long as the inside remains
more negative than the outside, the neuron will stay inactive.
 Action potential initiation and generation. Most neuron in the body are
excited by neurotransmitters released by other neurons; regardless what the
stimulus is, the result is always the same- the permeability properties of the
cell’s plasma membrane change for a very brief period.
  Depolarization. The inward rush of sodium ions changes the polarity of the
neuron’s membrane at that site, an event called depolarization.
 Graded potential. Locally, the inside is now more positive, and the outside is
less positive, a situation called graded potential.
 Nerve impulse. If the stimulus is strong enough, the local depolarization
activates the neuron to initiate and transmit a long-distance signal called action
potential, also called a nerve impulse; the nerve impulse is an all-or-none
response; it is either propagated over the entire axon, or it doesn’t happen at
all;it never goes partway along an axon’s length, nor does it die out with
distance as do graded potential.
 Repolarization. The outflow of positive ions from the cell restores the electrical
conditions at the membrane to the polarized or resting, state, an event called
repolarization; until a repolarization occurs, a neuron cannot conduct another
impulse.
 Saltatory conduction. Fibers that have myelin sheaths conduct impulses
much faster because the nerve impulse literally jumps, or leaps, from node to
node along the length of the fiber; this occurs because no electrical current can
flow across the axon membrane where there is fatty myelin insulation

THE NERVE IMPULSE PATHWAY

How the nerve impulse actually works is detailed below.

 Resting membrane electrical conditions. The external face of the membrane

is slightly positive; its internal face is slightly negative; the chief extracellular ion
is sodium, whereas the chief intracellular ion is potassium; the membrane is
relatively permeable to both ions.
 Stimulus initiates local depolarization. A stimulus changes the permeability
of a “patch” of the membrane, and sodium ions diffuse rapidly into the cell; this
changes the polarity of the membrane (the inside becomes more positive; the
outside becomes more negative) at that site.
 Depolarization and generation of an action potential. If the stimulus is
strong enough, depolarization causes membrane polarity to be completely
reversed and an action potential is initiated.
  Propagation of the action potential. Depolarization of the first membrane
patch causes permeability changes in the adjacent membrane, and the events
described in (b) are repeated; thus, the action potential propagates rapidly
along the entire length of the membrane.
 Repolarization. Potassium ions diffuse out of the cell as the membrane
permeability changes again, restoring the negative charge on the inside of the
membrane and the positive charge on the outside surface; repolarization occurs
in the same direction as depolarization.

COMMUNICATION OF NEURONS AT SYNAPSES

The events occurring at the synapse are arranged below.

 Arrival. The action potential arrives at the axon terminal.

 Fusion. The vesicle fuses with plasma membrane.
 Release. Neurotransmitter is released into synaptic cleft.
 Binding. Neurotransmitter binds to receptor on receiving neuron’s end.
 Opening. The ion channel opens.
 Closing. Once the neurotransmitter is broken down and released, the ion
channel close.

AUTONOMIC FUNCTIONING
Body organs served by the autonomic nervous system receive fibers from both
divisions.

 Antagonistic effect. When both divisions serve the same organ, they cause
antagonistic effects, mainly because their post ganglionic axons release
different transmitters.
 Cholinergic fibers. The parasympathetic fibers called cholinergic fibers,
release acetylcholine.
 Adrenergic fibers. The sympathetic postganglionic fibers, called adrenergic
fibers, release norepinephrine.
 Preganglionic axons. The preganglionic axons of both divisions release
acetylcholine.
SYMPATHETIC DIVISION
The sympathetic division is often referred to as the “fight-or-flight” system.

 Signs of sympathetic nervous system activities. A pounding heart; rapid,

deep breathing; cold, sweaty skin; a prickly scalp, and dilated pupils are sure
signs sympathetic nervous system activities.
 Effects. Under such conditions, the sympathetic nervous system increases
heart rate, blood pressure, and blood glucose levels; dilates the bronchioles of
the lungs; and brings about many other effects that help the individual cope with
the stressor.
 Duration of the effect. The effects of sympathetic nervous system activation
continue for several minutes until its hormones are destroyed by the liver.
 Function. Its function is to provide the best conditions for responding to some
threat, whether the best response is to run, to see better, or to think more clearly.

PARASYMPATHETIC DIVISION
The parasympathetic division is most active when the body is at rest and not
threatened in any way.

 Function. This division, sometimes called the “resting-and-digesting” system,

is chiefly concerned with promoting normal digestion, with elimination
of feces and urine, and with conserving body energy, particularly by decreasing
demands on the cardiovascular system.
 Relaxed state. Blood pressure and heart and respiratory rates rate being
regulated at normal levels, the digestive tract is actively digesting food, and the
skin is warm (indicating that there is no need to divert blood to skeletal muscles
or vital organs.
 Optical state. The eye pupils are constricted to protect the retinas from
excessive damaging light, and the lenses of the eye are “set” for close vision.
VI. PATHOPHYSIOLOGY
VIII. NURSING CARE PLAN
A. Prioritization
Nursing diagnosis
Decreased Cardiac
output r/t mitral valve (Highly priority)
prolapse secondary to
decreased cardiac supply
of the blood as evidenced
by increased afterload
and preload resulting to
Dysrhythmia and
tachycardia (103 bpm).
Ineffective cerebral tissue
perfusion related to (Highly priority)
cerebral hypoxia due to
decrease blood flow in
the brain secondary to
blockages of the
intracerebral artery as
manifested by dizziness,
and headache
Acute pain related to
decrease cerebral (Highly priority)
perfusion secondary to
blockage of the
intracerebral artery due to
Priority Rationale
1 Sufficient cardiac output helps
keep blood pressure at the levels
needed to supply oxygen-rich
blood to your brain and other vital
organs.
2 The oxygen and nutrients
subsequently diffuse from the
blood into the interstitial fluid and
then into the body cells.
Insufficient arterial blood flow
causes decreased nutrition and
oxygenation at the cellular level.
Decreased tissue perfusion can
be temporary, with few or minimal
consequences to the health of the
patient, or it can be more acute or
protracted, with potentially
destructive effects on the patient.
When diminished tissue perfusion
becomes chronic, it can result in
tissue or organ damage or death.
3 Pain can affect the treatment and
the cooperation of the patient;
pain can also affect the breathing
due to nervousness. Pain hinders
or limits physical activity such as
 build-up of the embolus
as manifested by
headache with pain scale
of 6/10, presence of facial
grimace, and guarding
behavior
Activity intolerance
related to increase
oxygen demand due to
hypoxia secondary to
decrease oxygen in
circulation as manifested
by tachypnea 28 cpm,
difficulty of breathing, and
use of accessory muscle
Risk for aspiration related
to impaired
neuromuscular muscle as
evidenced by exhibiting
difficulty swallowing
without choking
Risk for fall related to
impaired nearby motor
area and affectation
within spinal decussation
as manifested by right
sided body weakness.
physiological needs that should
be achieved hence it is
accomplished by an intact and
functioning system, in such pain
must be relieved or eliminated to
fulfill physiological needs (Walker
BR and Hunter JAA, 2006).
4 Activity intolerance that is related
(Medium to body weakness is also health
Priority) threatening because this will lead
to poor body movement. There is
also discomfort which is
associated with difficulty in
moving.
5 Risk of aspiration is the 5th priority
(Medium priority) because of the trouble in
swallowing of the patient. This is
because food or liquid can get
stuck in the back of your throat
and go into your
airway. Aspiration can lead to
pneumonia, respiratory infections
(infections in your nose, throat, or
lungs), and other health problems
6 Falls are associated with
(Medium priority) increased lengths-of-stay,
increased utilization of health
care resources, and poorer health
outcomes.
 Impaired comfort r/t 7 A negative environment delays
irritation of the back of the (Medium priority) healing. When patients
throat and airway experience too much anxiety,
secondary to they don't recover as easily. An
inflammation of paranasal increase in stress hormones like
sinus as evidenced by (+) cortisol can lengthen illness
phlegm, crackles and
productive cough.
Impaired verbal 8 Impaired verbal communication
communication related to (Medium priority) placed at medium priority
affectation of the Broca’s because it can also sign of further
area due to damage of complication related to the
language dominant patient’s diagnosis.
cerebral hemisphere
secondary to left side
brain damage as
manifested by dysarthria,
and slurred speech
Disturbed Sleeping 9 Healthy sleep also helps the body
Pattern r/t poor tissue (Medium priority) remain healthy and stave off
perfusion secondary to diseases. Without enough sleep,
fatigue as evidenced by the brain cannot function
difficulty of breathing and properly.
tachypnea: 28 cpm
Risk for Impaired Skin 10 The risk of compromised skin
integrity r/t decrease (Medium priority) integrity should be given a
oxygen in circulation medium priority because it may
secondary to poor tissue result in more weakness, which
perfusion will slow down recovery.
B. Nursing Care Plan
Nursing Nursing
Assessment Planning Rationale Evaluation
Diagnosis Intervention

Subjective: Decreased Short term: Independent: 1. Decreases Short term:

“Ramdam na Cardiac output r/t After 4 hours of 1. Maintained oxygen Goal was met,
ramdam ko yung mitral valve nursing bedrest in consumption and after 4 hours of
pagod sa prolapse interventions the position of demand, nursing
katawan ko kahit secondary to patient will be comfort. reducing intervention the
wala naman decreased able to report or 2. Monitored vital myocardial patient reported
akong ginagawa” cardiac supply of display signs esp. workload and and displays
as verbalized by the blood as decreased heart rate and risk of decreased
the patient. evidenced by episodes of respiratory decompensation. episodes of
increased Dysrhythmia, rate and 2. Sudden Dysrhythmia,
Objective: afterload and Tachycardia, and cardiac rhythm Changes in vitals Tachycardia, and
-Dysrhythmia preload resulting tachypnea. 3. Provided signs may cause tachypnea.
-Fatigue to Dysrhythmia adequate rest of further
-Poor capillary and tachycardia Long term: periods. problems. Long term:
refill (<4 sec) (103 bpm). After 24 hours of 4. Noted skin 3. Conserves Goal was met,
nursing color and energy and after 24 hours of
-Tachycardia (103 interventions the presence and reduces cardiac nursing
bpm) patient will quality of workload. interventions the
-Tachypnea (28 participate in pulses. 4. Peripheral patient
cpm) behaviors and circulation participated in
Dependent:
activities that reduced when behaviors and
5. Administered
reduces the cardiac output activities that
supplemental
workload of the falls. reduces the
oxygen via
heart. 5. The failing heart workload of the
oxygen
may not be able heart.
facemask with
to respond to
4-5 Lpm as
increased
needed.
oxygen
6. Administered
demands.
Atorvastatin
Oxygen
80mg/tab once
saturation needs
a day orally.
to be greater
7. Administered
than 90%.
Lanoxin 0.25g
6. Atorvastatin is a
tablet once a
statin medication
day orally.
used to prevent
8. Administered
cardiovascular
Clopidogrel
 25mg tablet disease in those
once a day at high risk and
orally. to treat abnormal
lipid levels. For
the prevention of
Collaborative: cardiovascular
9. Encouraged disease, statins
the patient’s are a first-line
relative to note treatment.
any changes 7. Digoxin
within the (Lanoxin) helps
patient’s the heart beat
condition stable and with a
more regular
rhythm.
8. Clopidogrel is an
antiplatelet
medication used
to reduce the
risk of heart
disease and
 stroke in those at
high risk.
9. Family members
can give useful
information
about how the
patient functions
and can assist
patients in
adhering to
treatment
suggestions.
They can also
assist in keeping
track of drug
side effects as
well as
prodromal and
residual
symptoms.
 Nursing Nursing
Assessment Planning Rationale Evaluation
Diagnosis Intervention

Subjective: Ineffective Short term: Independent: Short term:

“Yung cerebral tissue After 30 mins of 1. Checked 1. Review trend in Goal was met,
pakiramdam ko perfusion related nursing mental status; level of after 30 mins of
eh nahihilo na to cerebral intervention the perform a consciousness nursing
nanakit yung ulo hypoxia due to patient will be neurological and changes in intervention the
kahit na ihiga ko decrease blood able to verbalize examination ICP patient was able
sya” as flow in the brain understanding of to verbalize
verbalized by the secondary to the treatment 2. Monitored Vital understanding of
2. Serve as
patient blockages of the regimen such as Signs and I&O the treatment
baseline data of
intracerebral medications, regimen such as
the healthcare
Objective: artery as elevating the medications,
3. Evaluated providers.
-(+) Headache manifested by head of the bed, elevating the
motor reaction Monitoring for
with pain scale of dizziness, and and physical head of the bed,
to simple output is
6/10 headache rehabilitation and physical
commands, essential
-(+) Dizziness rehabilitation
noting because the
-(+) Mild slurred
purposeful and patient is taking
speech
non-purposeful mannitol and
 movement. furosemide that
Long term: Document limb are both Long term:
After 2 days of movement and diuretics Goal was met,
nursing note right and after 2 days of
intervention the left sides nursing
3. Measures
patient will be individually intervention the
overall
able to maintain patient was able
awareness and
ways to improve 4. Evaluated to maintain ways
capacity to
tissue perfusion verbal to improve tissue
react to external
such as elevating reaction. perfusion such as
stimuli, and
the head of the Observe if elevating the
best signifies
bed, and patient is head of the bed,
condition of
changing position oriented to and changing
consciousness
every 2 hours person, place, position every 2
in the patient
and time; or is hours
whose eyes are
confused; uses
closed due to
inappropriate
trauma or who
words or
is aphasic.
phrases that
Purposeful
make little
movement can
sense.
comprise of
5. Provided rest grimacing or
periods withdrawing
between care from painful
activities and stimuli
prevent
duration of 4. Measures
procedures appropriateness
of speech
6. Elevated the
content and
head of the
level of
bed 450 angle
consciousness.
with neck in
If minimum
neutral position
damage has
unless
taken place in
contraindicated
the cerebral
cortex, patient
7. Turned the may be
patient side to stimulated by
side q2h verbal stimuli
but may show
Dependent:
8. Administered drowsy or
Tramadol uncooperative
50mg IV every
8 hours as 5. Constant

headache activity can

occurs as further increase

ordered. ICP by creating

a cumulative

9. Administered stimulant effect

Betahistine 24
6. This is to
mg orally every
promote venous
8 hours as
drainage
dizziness
occurs as
7. This is to
ordered
prevent
complication
Collaborative:
like decubitus
10. Encouraged
ulcer
the patient’s
relative to note 8. Tramadol is
any changes used to relieve
within the moderate to
patient’s moderately
condition severe pain,
including pain
after surgery.
The extended-
release
capsules or
tablets are used
for chronic
ongoing pain.

9. Betahistine is a
histamine
analogue
medicine that is
used to treat
symptoms of
Ménière's
syndrome such
as dizziness
 (vertigo),
ringing in the
ears (tinnitus),
loss of hearing
and nausea.
This medicine
works by
improving blood
flow in the inner
ear. This lowers
the buildup of
pressure.

10. Family
members can
give useful
information
about how the
patient
functions at
home and can
assist patients
in adhering to
treatment
suggestions.
They can also
assist in
keeping track of
drug side
effects as well
as prodromal
and residual
symptoms
 Nursing Nursing
Assessment Planning Rationale Evaluation
Diagnosis Intervention

Subjective: Acute pain related Short term: Independent: Short term:

“Ang sakit talaga to decrease After 2 hours of 1. Assessed and 1. Alteration of Goal was met,
ng ulo ko kaya cerebral perfusion nursing observe environment or after 2 hours of
pinapahinga ko secondary to intervention the additional removal of nursing
nalang sya pag blockage of the patient will be able stressors or stressors/ intervention the
sinusumpong ng intracerebral to displays sources of sources of patient was able
kirot” as artery due to improvement as discomfort discomfort will to displays
verbalized by the build-up of the evidenced by increase the improvement as
patient embolus as absence of effectiveness evidenced by
2. Assessed
manifested by guarding behavior of the absence of
changes of
Objective: headache with and facial grimace interventions guarding behavior
pain
-(+) Headache pain scale of 6/10, and for the and facial grimace
with pain scale of presence of facial Long term: patient to relax
3. Applied a
6/10 grimace, and After 24 hours of and rest Long term:
hot/cold
-(+) Facial guarding behavior nursing peacefully Goal was met,
compress to
Grimace intervention the after 24 hours of
-(+) Guarding patient’s pain will the area of 2. Assessing nursing
Behavior subside from 6/10 discomfort. changes in intervention the
-(+) Irritability to 0/10 as pain will help patient’s pain
evidenced by 4. Eliminated to determine subsided from
absence of factors that current 6/10 to 0/10 as
irritability, and may aggravate condition of evidenced by
headache to the pain patient and absence of
effectiveness irritability, and
5. Provided a
of nursing headache
quiet and no
intervention
disruptive
environment
3. Hot compress
with dim lights
decreases
and
pain and
comfortable
improves
temperature
blood flow,
when possible
cold compress

6. Encouraged lessens pain,

and assisted inflammation,

the patient to and muscle

perform deep spasticity
 breathing
exercise 4. Factors that
may be
precipitating
Dependent: or augmenting
7. Administered pain should
Tramadol reduce or
50mg IV every eliminated to
8 hours as enhance the
pain occurs as overall pain
ordered. management
program

Collaborative:
5. Comfort and a
8. Instructed the
quiet
patient’s
atmosphere
relative to
promote a
report
relaxed feeling
unrelieved
and permit the
pain
client to focus
on the
 relaxation
technique
rather than
external
distraction

6. Deep
breathing for
relaxation is
easy to learn
and
contributes to
pain relief and
reduction by
reducing
muscle tension
and anxiety

7. Tramadol is
used to relieve
moderate to
moderately
 severe pain,
including pain
after surgery.
The extended-
release
capsules or
tablets are
used for
chronic
ongoing pain

8. Unrelieved
pain may
indicate a
complication to
the patient’s
condition
 Nursing Nursing
Assessment Planning Rationale Evaluation
Diagnosis Intervention

Subjective: Activity Short term: Independent: Short term:

“Hindi ako intolerance After 8 hours of 1. Assessed the 1. In normal Goal was met,
makakilos ng related to nursing patient’s baseline adults, routine after 8 hours of
maayos dahil increase oxygen intervention the cardiopulmonary activities should nursing
pakiramdam ko demand due to patient will be status (e.g., heart not affect an intervention the
mabilis ako hypoxia able to do ADL’s rate, orthostatic increase in heart patient was able
mapagod” as secondary to but with minimal BP) before rate of more than to do ADL’s but
verbalized by the decrease oxygen assistance and initiating activity 20 to 30 beats per with minimal
patient in circulation as participate minute above assistance and
manifested by willingly in 2. Noted the rest. Older participate
Objective: tachypnea 28 necessary self- patient reports of patients are more willingly in
-Tachypnea 28 cpm, difficulty of care activities weakness, prone to necessary self-
cpm breathing, and discomfort and orthostatic drops care activities
-(+) DOB use of accessory Long term: difficulty in blood pressure
-(+) Use of muscle After 1 week of accomplishing with position Long term:
accessory muscle nursing task changes. Goal was met,
-(+) Fatigue intervention, the after 1 week of
-(+) Patient seeks patient will be 3. Monitored nursing
for assistance able to identify perception of 2.To help intervention, the
when performing energy causes of activity determine patient was able
ADL conservation intolerance patient’s current to identify energy
techniques to health status and conservation
enhance activity 4. Planned care evaluate techniques to
tolerance that with rest periods effectiveness of enhance activity
patient will between activities nursing tolerance that
demonstrate a intervention patient will
decrease in 5. Assisted with rendered demonstrate a
physiological activities and decrease in
signs of provide/monitor physiological
intolerance as client’s use of 3. Causative signs of
evidenced by assistive devices factors may be intolerance as
absence of temporary or evidenced by
tachypnea, and 6. Encouraged permanent as well absence of
DOB client to maintain as physical or tachypnea, and
positive attitude, psychological DOB
suggest use of
relaxation 4. Activities
techniques: should be planned
*deep-breathing ahead to coincide
exercises three or with the patient’s
more times daily peak energy level.
and *Walking in If the goal is too
room 1 to 2 low, negotiate
minutes TID
5. Assistive
7. Encouraged devices improve
verbalization of the patient's
feelings regarding mobility by
limitations assisting him in
overcoming
Collaborative: limitations
8. Instructed the
patient’s relative 6. To strengthen
to assist the one's well-being
patient as needed
7. This helps the
patient to cope.
Acknowledgment
that living with
activity
intolerance is both
physically and
emotionally
difficult.

8. To properly
perform ADL even
with assistance
 Nursing Nursing
Assessment Planning Rationale Evaluation
Diagnosis Intervention

Subjective: Risk for aspiration Short term: Independent: Short term:

“Nahihirapan related to After 30 mins of 1. Kept the head 1. Maintaining a Goal was met,
akong kumain sa impaired nursing of bed sitting position after 30 mins of
totoo lang kahit neuromuscular intervention the elevated when after meals nursing
sabaw pa yan” as muscle as patient will be able feeding and for may help intervention the
verbalized by the evidenced by to enumerate a half hour decrease patient was able
patient exhibiting difficulty measures to afterward aspiration to enumerate
swallowing prevent aspiration measures to
Objective: without choking such as 2. Supervised 2. Supervision prevent aspiration
-Patient exhibits positioning in the patient with helps identify such as
difficulty of semi-fowlers oral intake abnormalities positioning in
swallowing when eating and early and semi-fowlers
3. Provided foods
without choking drinking, cutting allows when eating and
with
-(+) Decrease gag the food into small implementation drinking, cutting
consistency
reflex pieces, and eating of strategies the food into small
that the patient
and drinking for safe pieces, and eating
can swallow
slowly as tolerated swallowing. and drinking
slowly as tolerated
Long term: 4. Allowed the 3. Thickened
After 1 week of patient to chew semisolid Long term:
nursing thoroughly and foods such as Goal was met,
intervention the eat slowly pudding and after 1 week of
patient will be free during meals hot cereal are nursing
from risk for most easily intervention the
5. Offered liquids
aspiration as swallowed and patient is free
after food is
evidenced by less likely to be from risk for
eaten
effective aspirated. aspiration as
swallowing Liquids and evidenced by
6. Stopped
without choking thin foods effective
continual
(e.g., creamed swallowing
feeding
soups) are without choking
temporarily
most difficult
when turning
for patients
or moving
with dysphagia
patient

4. Well-
7. Provided oral
masticated
care before
food is easier
and after
to swallow,
meals
food cut into
 small pieces
may also be
Dependent:
easier to
8. Performed
swallow
NGT as
needed
5. Ingesting food
ordered by the
and fluids
physician
together
increase
Collaborative:
swallowing
9. Educated the
difficulties
patient’s
relative to 6. When turning
keep the or moving a
patient in patient, it is
upright or difficult to keep
semi-fowler’s the head
position when elevated to
eating and prevent
drinking regurgitation
and possible
aspiration
10. Instructed the
7. Oral care
patient’s
before meals
relative to
reduces
report any
bacterial
signs of
counts in the
aspirations
oral cavity.
Oral care after
eating
removes
residual food
that could be
aspirated at a
later time

8. Commonly
used to
provide
adequate
nutrition and a
route for
medication
 administration
to patients with
dysphagia

9. Upright
positioning
decreases the
risk for
aspiration

10. Information
helps in
appropriate
assessment of
high-risk
situations and
determination
of when to call
for further
evaluation
 Nursing Nursing
Assessment Planning Rationale Evaluation
Diagnosis Intervention

Subjective: Risk for fall Short term: Independent: 1. Signs are vital Short term:
“Talagang related to After 30 mins of 1. Secured for patients at Goal was met,
ramdam ko yung impaired nearby nursing wristband risk for falls. after 30 mins of
panghihina ko motor area and intervention the identification Healthcare nursing
talaga” as affectation within patient will be able for patients at providers need intervention the
verbalized by the spinal decussation to identify way to risk for falls to to patient was able
patient as manifested by prevent falling remind acknowledge to identify way to
right sided body such as side rails healthcare who has the prevent falling
Objective: weakness up, keep out the providers to condition, for such as side rails
-(+) Decreased scattered rugs, implement fall they are up, keep out the
strength in right and put all the precaution responsible for scattered rugs,
side of the body weight in the behaviors implementing and put all the
-(+) Right sided strong side of the actions to weight in the
body weakness body when 2. Placed items promote strong side of the
- Side rails are moving the patient patient safety body when
usually lowered uses within and prevent moving
easy reach, falls
Long term: such as call
After 1 week of light, urinal, 2. Items that are Long term:
nursing water, and too far may Goal was met,
intervention the telephone require the after 1 week of
patient will be free patient to nursing
3. Maintained the
from fall as reach out or intervention the
side rails up
evidenced by ambulate patient is free
absence of unnecessarily from fall as
4. Had the
scattered rugs, and can evidenced by
patient wear
maintained the potentially be a absence of
proper
side rails up, and hazard or scattered rugs,
footwear when
holding in the grab contribute to maintained the
walking if it is
bars falls side rails up, and
tolerated
holding in the grab
3. To promote
5. Provided the bars
safety of the
patient with
patient
assistive
devices for
4. Advise patient
transfer and
to use nonskid
ambulation
socks to
prevent the
feet from
Collaborative: sliding upon
6. Referred to standing
physical
5. The use of gait
therapist
belts by all
health care
7. Taught the
providers can
patient’s
promote safety
relative how to
when assisting
safely
patients with
ambulate at
transfers from
home,
bed to chair
including using
safety
6. Physical
measures
rehabilitation is
such as
an essential
handrails in
care that can
the bathroom
help a patient
back, keep, or
8. Advised the
improve
family to stay
physical
with the patient
mobility
7. Helps relieve
anxiety at
home and
eventually
decreases the
risk of falls
during
ambulation in
their home
setting. Raised
toilet seats can
facilitate safe
transfer on and
off the toilet

8. Helps prevent
the patient
from
accidentally
falling.
 Nursing Nursing
Assessment Planning Rationale Evaluation
Diagnosis Intervention

Subjective: Impaired comfort Short term: Independent: 1. Deep Short term:

“nairita na ko sa r/t irritation of the After 2 hours of 1. Encouraged breathing Goal was met,
ubo ko” as back of the throat nursing deep breathing exercises may after 2 hours of
verbalized by the and airway interventions the exercises. increase nursing
patient. secondary to patient will be 2. Encouraged comfort. interventions the
inflammation of able to report or increased 2. Increased patient reports
Objective: paranasal sinus display feeling of warm water water intake feeling of
- (+) Phlegm as evidenced by improvement of intake to 1500 make help improvement of
- (+) Crackles (+) phlegm, comfort in his L a day. reduce phlegm comfort in his
- (+) Productive crackles and throat. and/or irritation throat. “naging
cough productive cough. Collaborative: of the throat. maginhawa
- Irritation of the Long term: 3. Administer 3. Oxygen may naman ang
back of the After 24 hours of 4-5L of help breathing lalamunan ko” as
throat. nursing supplemental of the patient. verbalized by the
interventions the oxygen via 4. Acetylcysteine, patient.
patient will reduce oxygen also known as
the inflammation facemask as N- Long term:
of paranasal needed. acetylcysteine,
sinus, phlegm, 4. Administer is a medication Goal was met,
crackles and Acetylcysteine that is used to After 24 hours of
productive cough. 600 mg in a loosen thick nursing
half glass of mucus interventions the
water once a 5. Ceftriaxone is patient reduce the
day orally. used to treat inflammation of
5. Administer certain kinds paranasal sinus
Ceftriaxone 2g of bacterial and shows dry
IV every 8 infections. cough and no
hours. signs of phlegm
or crackles.
 Nursing Nursing
Assessment Planning Rationale Evaluation
Diagnosis Intervention

Subjective: Impaired verbal Short term: Independent: Short term:

“Siguro kaya ako communication After 30 mins of 1. Provided an 1. An alternative Goal was met,
nahihirapan related to nursing alternative means means of aafter 30 mins of
magsalita at affectation of the intervention the of communication communication nursing
dahan dahan broca’s area due patient will be able (e.g., flash intervention the
kong sinasabi to damage of to enumerate 2. Kept out all the cards, symbol patient was able
mga salita ko kasi language alternative ways distractions such boards, to enumerate
dahil sa sakit kong dominant cerebral of communication as television and electronic alternative ways
to” as verbalized hemisphere such as writing, radio at a messaging) of communication
by the patient secondary to left use of nonverbal minimum when can help the such as writing,
side brain damage cues, and use of talking to patient patient express use of nonverbal
Objective: as manifested by symbols ideas and cues, and use of
3. Maintained eye
-(+) Slurred dysarthria, and communicate symbols
contact with
speech slurred speech Long term: needs
patient when
-(+) Dysarthria After 2 days of Long term:
speaking. Stand
-(+) Difficulty in nursing 2. To keep after 2 days of
close, within
maintaining usual intervention the patient nursing
communication patient will be able patient’s line of focused, intervention the
pattern to maintain use of vision decrease patient was able
-(+) Use of alternative ways stimuli going to to maintain use of
4. Gave the patient
nonverbal cues of communication the brain for alternative way of
ample time to
-(+) Difficulty in as evidenced by interpretation, communication as
respond
constructing writing in magic and enhance evidenced by
continuous slate and using the nurse’s writing in magic
5. Praised patient’s
sentence nonverbal cues ability to listen slate and using
accomplishments.
nonverbal cues
Acknowledge his
3. Patients may
or her frustrations
have defect in
field of vision,
6. Used short
or they may
sentences, and
need to see
ask only one
the nurses’
question at a time
face or lips to
7. Provided enhance their
concrete understanding
directions that the of what is
patient is being
physically communicated
capable of doing
 4. It may be
difficult for
patients to
Collaborative:
respond under
8. Referred to
pressure; they
speech therapist
may need
extra time to
9. Allow significant
organize
others the
responses, find
opportunity to ask
the correct
questions about
word, or make
the patient’s
necessary
communication
language
problem
translations

5. The inability to
communicate
enhances a
patient’s sense
of isolation and
may promote a
 sense of
helplessness

6. This method
allows the
patient to stay
focused on
one thought

7. Simple, one-
action
directions
enhance
comprehension
for the patient
with language
impairment

8. Specialized
services may
be required to
meet needs
9. It is vital for the
family to know
that there are
many ways to
send
information to
someone and
that time may
be needed to
understand the
special needs
of the patient
 Nursing Nursing
Assessment Planning Rationale Evaluation
Diagnosis Intervention

Subjective: Disturbed Short term: Independent: 1. This promotes Short term:

“Sa gabi hindi sya Sleeping Pattern After 2 hours of 1. Instructed regulation of Goal was met,
makatulog ng r/t poor tissue nursing patient to the circadian after 2 hours of
maayos minsan perfusion interventions the follow as rhythm, and nursing
nga magdamag secondary to patient will consistent a reduces the interventions the
siyang gising fatigue as verbalize rest daily schedule energy patient verbalized
tapos sa umaga evidenced by periods and for retiring and required for rest periods and
siya tulog” as difficulty of shows willingness arising as adaptation to shows willingness
verbalized by the breathing and to learn how to possible. changes. to learn how to
patient’s sister. tachypnea: 28 sleep or rest 2. Instructed 2. For the patient sleep or rest
cpm between patient to may need to between
Objective: disturbances. avoid large void during disturbances.
- (+) DOB fluid intake bedtime “ano ba dapat
- Tachypnea Long term: before bedtime 3. To promote ang gawin ko
(28 cpm) After 2 days of 3. Assisted the good rest para makatulog
- Fatigue nursing patient to a 4. To promote ako ng maayos”
- Not feeling interventions the comfortable sleep as verbalized by
well rested patient will position the patient.
- (+) irritability increase sense of 4. Taught patient 5. Deep
- Dark circles well-being and some breathing
under the feeling rested. techniques to exercises may Long term:
eyes promote sleep increase Goal was met,
- Altered mental like listening to comfort. After 2 days of
status music. 6. It can promote nursing
- Yawning 5. Encouraged sleep/rest. interventions the
deep breathing patient increased
exercises sense of well-
being and feeling
Collaborative: rested.
6. Instructed the
relative to
identify factors
that may
facilitate or
interfere with
normal
patterns of
sleep.
 Nursing Nursing
Assessment Planning Rationale Evaluation
Diagnosis Intervention

Subjective: Risk for Impaired Short term: Independent: 1. This is to Short term:
“Hindi ba siya Skin integrity r/t After 2 hours of 1. Turned the prevent Goal was met,
magkakasugat sa decrease oxygen nursing patient side to complication After 2 hours of
bandang puwet in circulation interventions the side q2h like decubitus nursing
kapag lagi siyang secondary to poor patient will 2. Encourage ulcer interventions the
nakaupo?” as tissue perfusion verbalize the adequate patient verbalized
2. Sufficient
verbalized by the preventive nutrition and the preventive
hydration and
patient’s sister. measures of hydration measures of
nutrition help
having decubitus (1500L/day) having decubitus
maintain skin
Objective: ulcer like turning 3. Cleaned, dry, ulcer like turning
turgor,
-Dry skin the patient and the patient
moisture, and
- (+) Right sided frequently and/or moisturized frequently and/or
suppleness,
body weakness putting pillow on a skin, putting pillow on a
which provide
-poor skin turgor bony prominence particularly bony prominence
resilience to
(<4 sec) of the patient. bony of the patient.
damage
- prolonged prominences,
caused by
upright position Long term: twice daily or Long term:
pressure.
After 2 days of as indicated by Patients with Goal was met,
nursing incontinence limited after 2 days of
interventions the or sweating. cardiovascular nursing
patient will show 4. Reinforced the reserve may interventions the
no signs of importance of not be able to patient shows no
decubitus ulcer turning, tolerate much signs of decubitus
such as redness mobility, and fluid. ulcers such as
and itch. ambulation. 3. Smooth, redness and itch.
supple skin is
Collaborative: more resistant
5. Communicate to injury.
with a dietician These
as appropriate. measures
prevent
evaporation
away from
skin. Avoid talc
which may
cause lung
injury.
4. These will
enhance their
sense of
efficacy and
can improve
compliance
with the
prescribed
interventions.
5. The dietician
can aid the
patient and
family in food
preferences to
meet adequate
nutritional and
hydration
goals.
X. DRUG STUDY

Medication Classification Mechanism Of Indication/Contraindication Side Effects/Adverse Nursing Consideration

Action effects
Brand Name: Proton Pump Inhibits Indication: Side effects: • Asses vital signs
Prilosec Inhibitor hydrogen- • This drug is also used to Frequent (7%): Headache. • Assess for possible
potassium treat conditions such as contraindications and
Generic Name: adenosine gastric or duodenal ulcers, Occasional (3%–2%): cautions.
Omeprazole triphosphatase gastroesophageal reflux Diarrhea, abdominal pain, • Check for abdominal
(H+ /K+ ATP disease (GERD), erosive nausea. pain, diarrhea, and
Dosage: 40 mg pump), an esophagitis constipation.
(Inflammation in the • Evaluate intake and
enzyme on the Rare (2%): Dizziness,
Route: esophagus), and output
surface of gastric asthenia, vomiting,
hypersecretory conditions
Through IV parietal cells. constipation, upper • Advise the
(conditions where your
Therapeutic respiratory tract infection, patient to take 30-60
stomach makes too much
Frequency: Effect: Increases back pain, rash, cough. minutes before meal,
acid).
OD gastric pH, preferably in the
• This drug is also used to morning.
reduces gastric treat stomach infections Adverse effects:
acid production. Pancreatitis, • Instruct the patient to
caused by the bacteria
hepatotoxicity, interstitial avoid
Helicobacter pylori.
driving or any hazardous
 Omeprazole is given to a nephritis occur rarely. May
activity.
patient who is taking a increase risk of C. difficile
infection.
• Provide safety and
multiple drug. Most of the
comfort measures if CNS
drugs prescribed to the effects occurs to prevent
patient is gastric irritant. injury.
Monitor the patient’s
Contraindication: nutritional status; Use
• Hypersensitivity to drug. small frequent meals
may be
 • Diarrhea from an infection • helpful if GI upset is a
with Clostridium difficile problem.
bacteria.
• Liver problems systemic
lupus erythematosus, an
autoimmune disease.
• inadequate vitamin B12.

Medication Classification Mechanism Of Indication/contraindication Side Effects Nursing Consideration

Action
Brand Name: 3rd generation Binds to bacterial Indication: Side effects: • Assess for history of
Rocephin, cephalosporin cell membranes, • Indicated in patient with Frequent: allergies, particularly
Forgram, antibiotics. inhibits cell wall serious infections of lower Discomfort with cephalosporins,
Keptrix synthesis, respiratory and urinary IM penicillin.
promoting tract. administration, • Obtain specimen for
Generic Name: osmotic • Indicated in patient with oral candidiasis culture and sensitivity
Ceftriaxone instability. neurologic complications, (thrush), mild tests before giving first
carditis and arthritis. diarrhea, mild dose.
Dosage: 2g Therapeutic • Patient with Gonorrhea abdominal • Assess oral cavity for
Effect: • Patient with bone and cramping, vaginal white patches on
Route: Bactericidal. joint infection candidiasis. mucous membranes,
Through IV • Patient with Meningitis tongue (thrush).
• Patient with Acute Occasional: Monitor daily pattern of
Frequency: bacterial otitis media. Nausea, serum bowel activity, stool
Q8 hrs. sickness–like consistency.
Contraindication: reaction (fever, • Mild GI effects may be
• Contraindicated with joint pain; usually tolerable (increasing
allergy to cephalosporin or occurs after severity may indicate
penicillin and related second course of onset of antibiotic-
antibiotics. therapy and associated colitis).
resolves after • Monitor I&O,
drug is renal function tests for
discontinued). nephrotoxicity, CBC. Be
alert for superinfection:
Rare: fever, vomiting,
Allergic reaction diarrhea, anal/genital
(rash, pruritus, pruritus, oral mucosal
urticaria), changes (ulceration,
thrombophlebitis pain, erythema).
(pain, redness,
 swelling at
injection site).

Adverse effects:
Antibiotic-associated
colitis, other
superinfections
(abdominal cramps,
severe watery
diarrhea, fever) may
result from altered
bacterial balance in
GI tract.
Nephrotoxicity may
occur, esp. in pts
with preexisting
renal disease. Pts
with history of
penicillin allergy are
at increased risk for
developing a severe
hypersensitivity
reaction (severe
pruritus,
angioedema,
bronchospasm,
anaphylaxis).
Drug Name Classification Mechanism Of Indication/contraindication Side Effects/Adverse effects Nursing Consideration
Action
Brand Name: Analgesics (non- Appears to inhibit Indication: Side effects:  assess onset, type,
Paracetamol opoid) antiseptic. prostaglandin Reduction of fever, temporary Rare: Hypersensitivity reaction. location, duration
synthesis in the relief of minor aches and pain of pain. Effect of
CNS and, to a caused by common cold and Adverse effects: Drug Name is
lesser extent, influenza, headache, Early Signs of Acetaminophen reduced if full pain
Generic Name: block pain sore throat, toothache, Toxicity: Anorexia, nausea, response recurs
Tylenol impulses through Backache, menstrual cramps and diaphoresis, fatigue within first prior to next dose.
etc.
peripheral action. 12–24 hrs.  Assess for fever.
Dosage: Acts centrally on  Many Over-the-
300 mg hypothalamic Contraindication: Later Signs of Toxicity: Vomiting, counter and
heat-regulating Contraindicated with allergy to right upper quadrant tenderness, prescription
Route: acetaminophen. Use of cautiously
center, producing elevated LFTs within 48–72 hrs products contain
IV with impaired hepatic function,
peripheral after ingestion. Antidote: acetaminophen;
chronic alcoholism pregnancy
vasodilation (heat lactation. Acetylcysteine be aware when
loss, skin calculating daily
Frequency:
erythema, dose.
PRN
diaphoresis).

Therapeutic
Effect:
Results in
antipyresis.
Produces
analgesic effect.
 Drug Name Classification Mechanism Of Indication/contraindication Side Effects/ Adverse Nursing Consideration
Action effects
Brand Name: Gastrointestinal . Indication: Side effects:  To minimize
Lactulose agent: Produces an Prevention treatment of portal Nausea, vomiting, diarrhea sweet taste,
hyperosmotic osmotic effect in systemic encephalopathy dilute with
laxative. colon; resulting treatment of constipation. water or fruit
Generic Name: distention promotes Adverse effects: juice or give
Cephulac peristalsis. Also Contraindication: Abdominal cramping, with food.
decreases ammonia, Contraindicated to patients on bloating, gas  Be prepared to
probably as a result low-galactose diet. replace fluid
Dosage: of bacterial loss.
50cc degradation, which Patients with GI obstruction or
lowers the pH of perforation toxic colitis mega
Route: colon contents. colon.
PO
Use cautiously in patients with
rectal or anal conditions such as
Frequency: rectal bleeding or large
ODHS hemorrhoids

Drug Name Classification Mechanism Of Indication/contraindication Side Effects Nursing Consideration

Action
Brand Name: Chemical Class: Binds to mu- Indication: Frequent  Reassess patient’s level
Ultram Cyclohexanol opioid receptors, To relieve moderate to chronic (25%–15%): of pain at least 30 mins
inhibits reuptake pain in adult who require around Dizziness, vertigo, after administration.
Analgesic of the clock treatment of their pain nausea, constipation,  Monitor CV and
Generic Name: Pregnancy norepinephrine, for an extended period of time. headache, drowsiness. respiratory status.
Tramadol Category: C. serotonin, With-hold dose and
Occasional notify prescriber if
inhibiting
Dosage: Contraindication: (10%–5%): Vomiting, respirations decrease
ascending and
50mg and 10cc Tramadol may increase central pruritus, CNS stimulation or rate is below 12
descending pain
pathways. nervous system and respiratory (e.g., nervousness, cpm.
Route: depression when combined anxiety, agitation,  For better analgesic
IM alcohol, narcotics, tranquilizer or tremor, euphoria, mood effect, give drug before
Therapeutic swings, hallucinations), onset of intense pain.
IV sedative hypnotics.
Effect: Reduces asthenia, diaphoresis,  Prepare naloxone as
pain. dyspepsia, dry mouth, antidote.
Frequency:
diarrhea.  Monitor patient for
q6
drug dependence.
Rare
(Less than 5%): Malaise,
vasodilation, anorexia,
flatulence, rash, blurred
vision, urinary
retention/frequency,
menopausal symptoms.

Adverse effects:
Seizures reported in
patients receiving
tramadol within
recommended dosage
range. May have
prolonged duration of
action, cumulative effect
in pts with hepatic/renal
impairment, serotonin
syndrome (agitation,
hallucinations,
tachycardia,
hyperreflexia). May
cause suicidal ideation
and behavior.
 Drug Name Classification Mechanism Of Indication/contraindication Side Effects Nursing Consideration
Action
Brand Name: HMG-CoA Inhibits HMG-CoA Indication:
Side effects:
Lipitor Reductase reductase, the Atorvastatin may be used as a • Use only after diet
Inhibitors. enzyme that preventive agent for non-fatal and other nondrug
catalyzes the early myocardial infarction, fatal and Frequent (16%):
therapies prove
Generic Name: step in cholesterol non-fatal stroke, revascularization Headache. ineffective. Patient
Atorvastatin synthesis. procedures, hospitalization for should follow a
Therapeutic Occasional (5%–2%): standard low-
congestive heart failure and angina
Effect: Decreases in patients with coronary heart Myalgia, rash, cholesterol diet
Dosage: pruritus, allergy.
80mg/tab LDL and VLDL, disease before and during
plasma therapy.
Rare
Route: triglyceride levels; • Before starting
increases HDL (Less than 2%):
PO Contraindication: treatment, assess
concentration. Flatulence, dyspepsia,
• Hypersensitivity to depression.
patient for
atorvastatin. underlying causes for
Frequency:
• Active liver disease or hypercholesterolemia
ODHS Adverse effects:
and obtain a baseline
unexplained transaminase Potential for
lipid profile.
elevation cataracts,
• Drug may be given as
photosensitivity,
• Patient with liver myalgia, a single dose at
anytime of day, with
problems rhabdomyolysis.
or without food.
• Women who are • WOF signs of
pregnant or myositis.
breastfeeding should not
take atorvastatin
 Drug Name Classification Mechanism Of Indication/contraindication Side Effects Nursing Consideration
Action
Brand Name: PHARMACO HF: Indication: Side effects: • Apical pulse
Lanoxin THERAPEUTIC: Cardiac Inhibits should be taken
glycoside. sodium/potassiu • Heart failure • Dizziness for a full minute
m ATPase pump • Supraventricular • Headache before
Generic Name: CLINICAL: in myocardial arrhythmias. • Diarrhea administration
Digoxin Antiarrhythmic, cells. Promotes • Rash of this
cardiotonic. • visual medication. If
calcium influx.
Dosage: Contraindication: disturbances the apical pulse
Supraventricular
0.25mg/tab is less than 60,
Arrhythmias:
• Hypersensitivity Adverse effects: the dose should
Suppresses AV
Route: • Ventricular Fibrillation be withheld and
node conduction. the prescribing
PO • Obstructive The most common
cardiomyopathy. early manifestations of provider
Therapeutic notified.
Frequency: digoxin toxicity are
Effect: • Serum digoxin
OD levels should be
GI disturbances
HF: Increases (anorexia, nausea, closely
contractility. vomiting) monitored
because
Supraventricular neurologic hypokalemia
Arrhythmias: abnormalities (fatigue, increases the
headache, depression, effects of
Increases
weakness, drowsiness, digoxin and can
effective
confusion, result in digoxin
refractory toxicity.
period/decreases nightmares). Facial
pain, personality • WOF signs of
conduction digoxin toxicity
change,
velocity,
decreases heart
ocular disturbances
rate. (photophobia, light
flashes, halos around
bright objects, yellow
or green color
perception) may
occur.

Sinus bradycardia, AV
block, ventricular
arrhythmias noted.

Antidote: Digoxin
immune FAB
 Drug Name Classification Mechanism Of Indication/contraindicati Side Effects/ Nursing Consideration
Action on adverse effects
Brand Name: Antihypertensive
Vasotec, inhibitor Suppresses renin- Indication Side effects: • Assess for allergy
Vaseretic ACE inhibitor angiotensin- Management of essential to enalapril,
aldosterone system Frequent (7%– impaired renal
or renovascular 5%): Headache,
Generic Name: (prevents hypertension, function, salt or
Enalapril conversion of dizziness. volume
asymptomatic left
angiotensin I to ventricular dysfunction in depletion.
Dosage: angiotensin II, a patients with an ejection • Monitor patients
5 mg/tab potent fraction of to 35 percent Occasional (3%– on diuretic
vasoconstrictor; to decrease the rate of 2%): Orthostatic therapy for
Route: may inhibit hypotension, excessive
development of overt
PO angiotensin II at hypotension after
heart failure and the fatigue,
local vascular, renal incidence of the first few doses
diarrhea, cough,
sites). Decreases of enalapril.
Frequency: hospitalization for heart syncope.
plasma angiotensin failure • Monitor patient
OD AM II, increases plasma closely in any
renin activity, situation that may
decreases Rare lead to a drop in
Contraindication
aldosterone BP secondary to
secretion. (Less than 2%):
Patients with reduced fluid
Angina,
hypertensive to this volume (excessive
- Prevents abdominal pain,
product and history of perspiration and
vasoconst vomiting, dehydration,
Angio edema
riction by nausea, rash, vomiting,
blocking asthenia. diarrhea) because
Angiotnes excessive
in 1 and 2 hypotension may
receptor Adverse effects: occur
 Excessive • Monitor patient
hypotension carefully because
Therapeutic Effect: ("first-dose peak effect may
In hypertension, syncope") may not be seen for 4
reduces peripheral occur in pts with hr. Do not
arterial resistance. HF, severe salt administer
In HF, increases second dose until
or volume
cardiac output; BP has been
depletion.
decreases checked.
Angioedema
peripheral vascular • Advise the
resistance, B/P, (facial, lip patient to report
pulmonary swelling), if he/she
capillary wedge hyperkalemia experience
pressure, heart occurs rarely. nagging cough
size. Agranulocytosis,
neutropenia
may be noted in
pts with renal
impairment,
collagen
vascular
diseases
(scleroderma,
systemic lupus
erythematosus).
Nephrotic
syndrome may
be noted in
those with
history of renal
disease.
 Drug Name Classification Mechanism Of Indication/contraindicati Side Effects/ Nursing Consideration
Action on Adverse effects
Brand Name: Nonsteroidal anti- Exact mechanism
Aspirin inflammatory for anti- Indication Side effects: • Use caution in bleeding
drugs (NSAIDs) inflammatory, Integumentary  upset disorders, chronic alcohol
analgesic, structures, myalgia, stomach; use
antipyretic effects neuralgia, headache,
unknown. dysmenorrhea gout.  heartburn; • May lead to Stevens-
Generic Name:
acetylsalicylic Inhibition of  drowsines Johnson syndrome,
acid. enzyme cyclo- Arthritis, SLE acute s; or. laryngeal edema, and
oxygenase, the rheumatic fever.  mild anaphylaxis
Dosage: enzyme headache.
80mg tab responsible for • Increases risk for
prostaglandin Contraindication bleeding with warfarin,
synthesis, appears Adverse heparin, and clopidogrel
Route:
to be a major Hypersensitivity to effects: • Increased risk for GI
PO
mechanism of salicylates, severe • Stomach bleeding with NSAID use
Frequency: action. May inhibit anemia, history of blood pain
other mediators of coagulation defects, • Heartburn • Monitor liver function
OD
inflammation (e.g., vitamin k deficiency 1 tests
• Nausea
leukotrienes). week before and after
Direct action on surgery • Vomiting • Concurrent use with
hypothalamus • Ulceration alcohol may increase risk
heat-regulating • Perforatio for GI bleeding
center may n
contribute to
• Severe
antipyretic effect.
gastrointe
stinal (GI)
bleeding
• Dyspepsia
(the most
frequent
adverse
reaction)
 Drug Name Classification Mechanism Of Indication/contraindicati Side Effects/ Nursing Consideration
Action on Adverse effects
Brand Name:  May cause GI
Plavix Anti-platelet Inhibits binding of Indication Side effects: bleeding,
Adenosine enzyme adenosine neutropenia,
phosphate (A DP) phosphate (ADP) to Treatment of patients at Frequent (15%):
hypercholesterole
receptor its platelet risk for ischemic events- Skin disorders. mia
Generic Name: antagonist receptor and history of MI ischemic 
Clopidogrel subsequent ADP- stroke, peripheral artery May increase risk
Occasional (8%–
mediated disease. for bleeding in
activation of a 6%): Upper
warfarin, aspirin,
glycoprotein Patients with acute respiratory tract
heparin
Dosage: complex. coronary syndrome infection, chest 
75 mg . pain, flu-like Can increase risk
Therapeutic Effect: Contraindication symptoms, for bleeding with
Inhibits platelet Allergy to clopidogrel headache, garlic, ginkgo,
Route: aggregation. active pathological dizziness, ginger
PO bleeding such as peptic arthralgia 
ulcer or intracranial Monitor for signs
Rare
hemorrhage, lactation. of bleeding
(5%–3%):
Frequency: Monitor bleeding
Cautiously with bleeding Fatigue, edema, times
OD
disorders recent surgery hypertension, 
and hepatic impairment abdominal pain, Monitor CBC and
dyspepsia, platelet count
diarrhea,
nausea,
epistaxis,
dyspnea,
rhinitis.
Name of Classification Mechanisms of Indication Side Effect/ Nursing Consideration
Drugs Action /Contraindication adverse effects
Side effects:
Brand Name: Anti-coagulant Potentiates action Indication • Contraindicated in pork
Lovenox Cardiovascular of antithrombin III, Occasional (4%– hypersensitivity
inactivates Treat blood clots; Treat 1%): Injection
Generic Name: coagulation factor angina and heart attacks site hematoma, • Monitor for signs of
Enoxaparin Xa. nausea, bleeding
peripheral
Dosage: Therapeutic Effect: Contraindication • Administer in
edema.
0.4cc Produces subcutaneous tissue
anticoagulation. Active major bleeding,
Adverse effects:
Route: Does not thrombocytopenia with • DO NOT eject air bubble
SQ significantly anti-platelet antibody in prior to injection
May lead to
influence PT, aPTT.. presence of enoxaparin
bleeding
or heparin • DO NOT aspirate or
complications
Frequency: OD ranging from massage site
local
ecchymoses to  Monitor VS and
major
hemorrhage. assess for signs
May cause of bleeding
heparin-induced
thrombocytope
nia (HIT).
Antidote: IV
injection of
protamine
sulfate (1%
solution) equal
to dose of
 enoxaparin
injected. 1 mg
protamine
sulfate
neutralizes 1 mg
enoxaparin. One
additional dose
of 0.5 mg
Name of Classification Mechanism of Indication/Contraindica protamine
Side Effect Nursing Consideration
Drugs Action tion sulfate per 1 mg
Betahistine affects enoxaparin may
Side effects:
be given if aPTT
Anti-emetics the histaminergic Indication tested
Nausea • Instruct patient
Brand Name: Anti-vertigo system: Betahistine 2–4 hrs that medication
after
Headache
first
Serc acts both as a Indicated for treatment will take with
injection
Allergic skin
partial histamine of Meniere’s syndrome meals.
reactions
remains
Generic Name: H1-receptor agonist symptoms which may
such as
prolonged.
Betahistine and histamine H3- include vertigo, tinnitus,
itching and • Encourage the
Dihydrochloride receptor hearing loss and nausea. patient to bathe
rash.
antagonist also in in warm water
Dosage: neuronal tissue, Contraindication using a mild soap,
24mg and has negligible Patients with Adverse effects: then air dry the
H2-receptor phaeochromocytoma skin and gently
 Urticaria
Route: activity. Betahistine and to patients with pat to dry.
PO increases hypersensitivity to any  Pruritus
• Assess
histamine turnover component of the  Mild gastric respirations and
and release by product.
complaints adventitious
Frequency blocking
 False sounds.
q8 presynaptic H3-
receptors and heartbeat
inducing H3-
 Insomnia
receptor down
regulation.
Name of Classification Mechanisms of Indication/Contraindica Side Effect Nursing Consideration
Drugs Action tion
Side effects:
Brand Name: Aldosterone Interferes with Indication: • contraindicated
Aldactazide Antagonist sodium Management of edema Frequent: with hyperkalemia
Aldactone reabsorption by in cirrhotic adults not Hyperkalemia (in
competitively responsive to fluid and pts with renal
Generic Name: inhibiting action of sodium restrictions, insufficiency, • monitor intake and
Spironolactone aldosterone in primary those taking output
distal tubule, hyperaldosteronism potassium
Dosage: promoting sodium short-term supplements), • monitor blood
25 mg, ½ tab and water preoperatively, primary dehydration, pressure
excretion, hyperaldosteronism hyponatremia,
Route: increasing long-term in patients lethargy.
PO potassium with aldosterone
• monitor potassium
retention. producing adrenal Occasional: levels and renal
adenomas that are not Nausea, panel
Frequency: Therapeutic Effect: candidates for surgery vomiting,
OD Produces diuresis, or patients with bilateral anorexia,
lowers B/P. micro/macronodular abdominal
adrenal hyperplasia, as cramps, diarrhea,
an add-on therapy in headache, ataxia,
hypertension, and in drowsiness,
nephrotic syndrome confusion, fever.
when treatment of the Male:
disease as well as fluid Gynecomastia,
and sodium restriction impotence,
decreased libido.
with other diuretics is Female:
inadequate Menstrual
irregularities
(amenorrhea,
Contraindication: postmenopausal
Allergy to bleeding), breast
spironolactone, tenderness.
hyperkalemia, renal
disease, anuria, Rare:
amiloride or Rash, urticaria,
triamterene. hirsutism.

Adverse effects:

Severe
hyperkalemia
may produce
arrhythmias,
bradycardia, EKG
changes (tented
T waves,
widening QRS
complex, ST
segment
depression). May
proceed to
cardiac standstill,
ventricular
fibrillation.
Cirrhosis pts at
risk for hepatic
decompensation
if dehydration,
 hyponatremia
occurs. Pts with
primary
aldosteronism
may experience
rapid weight loss,
severe fatigue
during high-dose
therapy.

Name of Classification Mechanisms of Indication Side Effect Nursing Consideration

Drugs Action /Contraindication
Stimulates motility Side effects:
Brand Name: Antiemetic of upper GI tract. Indication:  Assess for
Gimoti, Reglan Prokinetic Blocks Metoclopramide in the Frequent (10%): allergy to
dopamine/serotoni oral tablet form is used Drowsiness, metoclopramide,
Generic Name: n receptors in for symptomatic restlessness, GI hemorrhage,
Metoclopramide chemoreceptor treatment of both acute fatigue, lethargy. mechanical
trigger zone. and recurrent diabetic obstruction or
Enhances gastroparesis, in Occasional (3%): perforation,
Dosage: acetylcholine addition to the Dizziness, pheochromocyto
10 mg response in upper treatment of anxiety, ma, epilepsy,
GI tract; increases gastroesophageal reflux headache, lactation,
Route: lower esophageal disease (GERD) in insomnia, breast previously
IV sphincter tone. patients who have failed tenderness, detected breast
to respond to traditional altered cancer.
Therapeutic Effect: therapy. A nasal spray menstruation,  Monitor BP
Frequency: Accelerates formulation is also constipation, carefully during IV
intestinal transit, indicated to treat adults rash, dry mouth, administration.
OD promotes gastric with acute, recurrent galactorrhea,  Monitor for
emptying. Relieves diabetic gastroparesis gynecomastia. extrapyramidal
nausea, vomiting. reactions, and
 Rare (less than consult physician if
3%): they occur.
Hypotension,  Keep
hypertension, diphenhydramin
tachycardia. e injection
Contraindication: readily available
Adverse effects: in case
Sensitivity of intolerance extrapyramidal
to metoclopramide. Extrapyramidal reactions occur
reactions occur (50 mg IM).
Allergy to sulfiting most frequently  Have
agents, history of in children, phentolamine
seizures disorders. young adults readily available
(18–30 yrs) in case of
Concurrent use of drugs receiving large hypertensive
that can cause doses (2 mg/kg) crisis (most likely
extrapyramidal during to occur with
symptoms. chemotherapy undiagnosed
and usually are pheochromocyto
limited to ma).
akathisia
(involuntary limb
movement, facial
grimacing, motor
restlessness).
Neuroleptic
malignant
syndrome
(diaphoresis,
fever, unstable
B/P, muscular
rigidity) has been
reported.
Name of Classification Mechanisms of Indication Side Effect Nursing Consideration
Drugs Action /Contraindication
Exerts a Side effects:
Brand Name: Penicillin bactericidal action Indication: Before
Penicillin G Anti-infective, against penicillin- Severe infections caused  Nausea
procaine Antibiotic susceptible by sensitive organisms  Vomitin  Observe 15 rights
microorganisms (streptococci) g of drug
Generic Name: during the stage of  Upset administration.
Benzathin active - URTI caused by stomac  Reduce dosage
Benzylpenicillin multiplication. It sensitive streptococci h with hepatic or
acts through the  Mild renal failure.
- Treatment of syphilis,
inhibition of skin  Assess for
Dosage: biosynthesis of cell- bejel, congenital hypersensitivity
rash
1.2M units wall peptidoglycan, syphilis, pinta, yaws
 Muscle to drug.
rendering the cell
- Prophylaxis of spasm  Assess for any
Route: Therapeutic contraindications
rheumatic fever and
Gluteus minimus Effect: Adverse effects: to the drug.
chorea
Works by stopping  Educate about
the growth of  Chills side effects of
Frequency: bacteria, prevents  Muscle drug.
certain infection pain During
Every 21 days caused by bacteria.
 Headac
Contraindication: he  Drug is not for IV
 Tachyca use. Do not inject
Concentrations rdia or mix with other
 Flushin IV solutions.
- Allergies to penicillins,  Give IM injection
g
cephalosporins, or other
 Tachyp in upper outer
allergens quadrant of the
nea
 Hypote buttock.
nsion
Precaution  Avoid contact
with the needle.
- Renal disorders
 Penicillin G is
- Pregnancy given with
lidocaine.
- Lactation  Use aspirating
needle whhen
withdrawing the
Drug interaction medication
 Withdraw needle
Drug to drug
as quickly as
- Decreased possible to avoid
effectiveness with discomfort.
tetracyclines  Stay with patient
throughout
- Inactivation of whole duration
parenteral of
aminoglycosides administration.
(amikacin, gentamicin, After
kanamycin, neomycin,
tobramycin)  Monitor client
for at least 30
minutes.
 Arrange for
Drug to food
regular follow-
- none reported up, including
blood tests, to
evaluate effects.
 Instruct to report
difficulty
breathing,
rashes, severe
 pain at injection
site, mouth
sores, unusual
bleeding or
bruising.
 Instruct to take
medication as
directed for the
full course of
therapy, even if
feeling better.
Xi. DISCHARGE PLAN

MEDICATION

 Instructed the relative and the patient to go to the hospital every 21 days for
penicillin g 1.2-million-unit deep IM administration to prevent recurrent attacks
of rheumatic fever.
 Advised the patient to continue the prescribed home medication such as
enalapril 5mg/tab and Lanoxin 0.25 mg/tab once a day.
 Advised the relative and the patient to take the pulse rate before giving Lanoxin.
Pulse rate should be 60-100 before giving the medication.
 Advised the patient that antibiotic prophylaxis is recommended before dental
procedure because it can cause perforation of oral mucosa which can make the
patient acquire infection.
 Advised the patient to not self-medicate with other antibiotics.
 Advised the patient and relative to incorporate the therapeutic plan into
everyday activities. To attain therapeutic effect.

EXERCISE

 Instructed the relatives to do passive exercise on patient to prevent spasticity

and muscle stiffness.
 Encouraged the patient to engage in 20-60 minutes of aerobic exercise such
as walking three to seven days per week. The exercise can be done in 10 mins
intervals with the goal of being at least 20 mins per day.
 Advised the patient that rest period should be planned, and activities spaced to
give rest between activities. To improve cardiac activity
 Encouraged the patient to seek assistance in doing some activities of daily
living if needed.
 Promote deep breathing exercise for the patient, effective deep breathing
exercise and coughing will help clear and maintain a patent airway and prevent
airway collapse.

TREATMENT
  Emphasized to the patient the importance of prophylaxis against recurrent of
sore throat and continuous therapy to prevent rheumatic fever.
 Explained to the patient of continuing home medications as prescribed by the
doctors.
 Advised the patient to maintain adequate blood pressure levels to prevent
precipitation of cerebral hemorrhage.
 Instructed the relative of the patient to improve physical mobility of the patient
with their help and maintain the patient’s skin integrity by urning the patient
every 2 hours if tolerated.

HEALTH TEACHING

 Advised the patient that good oral hygiene is very important. Poor dental
hygiene can lead to bacteremia. Personal oral care includes using a soft
toothbrush and toothpaste to brush teeth, gums, tongue, and oral mucosa at
least twice a day.
 Advised the patient to avoid using toothpicks or other sharp objects in the oral
cavity.
 Advised the patient and relatives to lessen emotional stress as it precipitates
chest pain.
 Advised the patient to avoid body piercing, and tattooing that may increase the
risk of acquiring infection.
 Advised the patient and relative that infection control and prevention requires
good hand hygiene.
 Encouraged the patient’s relatives to keep their environment clean, an practice
proper food handling to prevent recurrent of infection.
 Advised the relatives of the patient to remove rugs in the house to prevent injury.
 Encouraged the patient to have adequate sleep to have enough rest.

OUT-PATIENT CARE

 Referred the patient to rehab, need for physical therapist.

 Advised the patient to report if the fever and sore throat occurs for over 7 days.
 Emphasized the importance of regular follow up check-ups and as instructed
by physician.
DIET

 Encouraged the patient to avoid foods high in fats such as “pares” and street
foods to prevent elevation of blood pressure that may predispose to other
complications. Avoiding street foods will also prevent the patient from acquiring
infections.
 Advised the patient to follow DASH diet such as fruits and vegetables, moderate
in low fat products, and white meat for protein.
 Instructed the patient’s family to prepare a low sodium low fat diet. Diet of the
patient should be low salt and low fat to avoid elevation of blood pressure.