COLEGIO SAN AGUSTIN BACOLOD

COLLEGE OF HEALTH AND ALLIED

PROFESSIONS NURSING PROGRAM
B.S. Aquino Drive, Bacolod City
Contact Number: (034) 434 – 24 71 Local
162 Email Address: csab.chap@gmail.com

CASE STUDY FORMAT

(MEDICAL)

Summary of the Case:

Mrs. B. is a 54 y.o. Female was admitted accompanied by her daughter in a wheelchair because
of left sided body weakness. Before she was brought to the hospital, she went to do some errands on
her pigsty. Due to extreme heat, she began to sweat profusely, felt dizzy and loose the ability to maintain
balance. In addition, she manifested numbness and weakness on her left upper and lower extremities,
slight confusion and slurring of speech. Her daughter noticed that she is struggling to stand and quickly
realized that her condition is getting worse. Upon admission, vital signs were taken BP= 170/90 mmHg,
T=37.5° C, PR=110 bpm, RR= 22 bpm, Sp02= 95%.

I. Objectives:
This Case Study aims to:
Knowledge:

● Determine the medical history of the patient accurately.

● Prioritize the following problems manifested by the patient accordingly.
● Organize a case study presentation properly.
● Identify the mechanism of action of each ordered medication correctly.
● Evaluate the effectiveness of nursing care rendered.

Skills:

● Collect important information from the patient accurately.

● Perform a comprehensive cephalocaudal assessment.
● Provide relevant questions during the interview appropriately.
● Maximize all the resources during the course of the case study properly.
● Develop a discharge plan appropriate to the patient.

Attitude:

● Manifest Augustinian core values at all times.

● Respect the beliefs of the patient and significant others.
● Maintain professionalism when working with the case.
 ● Develop commitment in accomplishing the case study.
● Demonstrate positive attitude towards criticism and corrections.

II. Patient’s Profile:

a. Name : D. F. B.
b. Address: Bacolod City
c. Age: 54
d. Status: Married
e. Educational Status: High School Graduate
f. Occupation: Farmer Hogwer

Medical Diagnosis: Acute Cardio Vascular Disease infarct Right Middle Cerebral Artery with Left
hemiplegia (Acute Ischemic Stroke)
Date of Admission: March 25, 2023
Physician: Dr. M.
Hospital: Metro Bacolod Hospital and Medical Center

III. Nursing History

A. Present Illness
The patient is manifesting numbness and weakness on her left upper and lower
extremities, slurring of speech, headache and increased in blood pressure. Additionally, patient
also have a goiter and is diabetic.

B. Past medical history

She already experienced two strokes before. Both times she was hospitalized because of
left sided paralysis and numbness. She was hospitalized in 2020 at Sanitarium and again in 2021
at Metro Bacolod Hospital. Her daughter claimed that after a week of her admission she was
able to gain back her motor function on her left side. She was able to walk and move her hands
and feet.

Patient has hypertension and is diabetic. Her only maintenance is Losartan.

C. Family History
Patient’s father side has a history of stroke ,goiter, and hypertension. On her mother side
she claimed that there are no disease condition.

D. Socio-cultural history
Patient job is working and managing her family’s pigsty. She woke up early everyday to
feed her animals and also worked during afternoon under extreme heat. Since she was born and
raised doing work at a farm, she is able to do work and errands for longer periods and do
multitasking. Patient does not engage in any exercise because she claimed its too tiring for her
and her job at the pigsty is enough for her to keep her body active. Patient is also actively
 participating in their community. She always joins in the barangay meetings, gatherings and
events. Patient does not smoke and drink alcohol. Her diet mainly consists of vegetables and
fruits,pork and meat, and occasionally he eats chicken, and fish.

IV. Assessment
A. Nursing Assessment
1. General Description
Weight: 70 kgs
Height: 5’2
Body built: Endomorph
Appearance: Patient looks tired, has a fair complexion, neatly groomed and clean
clothes

2. Systemic Assessment .
Vital Signs/Stats
Temp: 37.5 ° C
PR: 110 bpm
RR: 22bpm
BP: 170/90 mmHg
Sp02: 95%

Neurological:
- Eye Opening: Spontaneous
- Verbal Response: Incomprehensible sounds
- Motor Response: No Response (L)
- Cerebellar Deficits (Coordination)
- Gait abnormalities (position, balance)

National Institutes of Health (NIH) Stroke Scale

Category Scale and Description

1a. Level of Concsiousness 0 - Alert; Keenly responsive

1b. Level of Concsiousness questions (month, 0- Answers both questions correctly
age)
1c. Level of Concsiousness commands (open, 1- Obeys one correctly
close eyes ; make fist, let go)

2. Best gaze (eyes open-patient follows 0- Normal

examiner’s finger or face)

3. Visual (introduce visual stimulus/threat to 0- Normal

patient’s visual field quadrants)
 4. Facial palsy (show teeth, raise eyebrows, and 2- Partial Paralysis (total or near-total paralysis of
squeeze eyes shut) lower face).

5a. Motor; arm – Left (elevate extremity to 90 4- No movement

degrees and score drift/movement)
5b. Motor; arm – Right (elevate extremity to 90 0- = No drift; limb holds 90 (or 45) degrees for full
degrees and score drift/movement) 10 seconds.

6a. Motor; leg – Left (elevate extremity to 30 4- No movement

degrees and score drift/movement)
6b. Motor; leg – Right (elevate extremity to 30 0- No drift; leg holds 30-degree position for full 5
degrees and score drift/movement) seconds

7. Limb ataxia (finger-to-nose and heel-to-shin 0- Absent

testing)

8. Sensory (pinprick to face, arm trunk, and leg) 2-Severe to total sensory loss; patient is not
aware of being touched in the face, arm, and leg
on affected site.

9. Best language (name items, describe picture, 0- No aphasia

and read sentences)

10. Dysarthria (evaluate speech clarity by having 1- Mild to moderate dysarthria

patient repeat words)

11. Extinction and inattention (use information 0- No abnormality

from prior testing score)

TOTAL : 14 (Moderate Stroke)

HEENT:
Head/Face:
-Black hair evenly distributed.
-No lesions, redness, or scaliness
-Round and symmetrical smooth and not tender
- Asymmetrical facial expressions
Eyes:
-Eyebrow and eyelash evenly distributed
-Pinkish palpebral conjunctiva
-Anicteric sclera
-PERRLA:
Right eye : Pupils are black, round and equal diameter, his pupil constricted to 3mm
Left eye : Pupils are black, round and equal diameter, his pupil constricted to 3mm
Ears:
-Auricles are symmetrical and have the same color as facial skin; it is also align with the outer
canthus of the eye.
-No discharge and swelling present intympanic membrane.
-Whisper test: Normal. The client is able to repeat whispered words.

Nose:
- Symmetric and straight
-No discharge and lesions.
-Smell normally; smells and odors are perceived

Mouth:
-Pale, dry cracked lips
-No gums inflammation or infection.
-Palate and buccal mucosa are intact.

Respiratory:
-Symmetric chest expansion
-Clear breath sounds

Circulatory System:
-BP= 170/90 mmHg
-Capillary Refill: 2 second; Normal
-Carotid & temporal artery palpation: Carotid: 110 bpm; Temporal: 110 bpm
-Heart auscultation: 110 bpm

Gastrointestinal:
- Symmetrical movements caused by respirations.
Inspection
- Unblemished Skin, uniform in color, symmetric contour, not distended
Auscultation
- Hypoactive bowelsounds noted.
Palpation
- No mass and tenderness noted.
Percussion
- Tympanic sounds upon percussion noted.

Genitourinary:

- Bladder: With diaper (Changes once)

 - Urine Characteristics: Yellowish
- MIO
Input: 500cc
Output: 400cc; Soaked Diaper

Musculoskeletal system
- No muscle strength (L)
- 0/5: Complete paralysis on the left side
- DTR Grading: (R)
Biceps: 2+
Brachioradialis: 2+
Triceps: 2+
Patellar: 2+
Ankle: 2+
Average, expected response; normal

(L)
Biceps: 0
Brachioradialis: 0
Triceps: 0
Patellar: 0
Ankle: 0
: No response, absent

Integumentary
-Pallor
-No lesions, abrasions and scars noted
-Warm to touch
-Skin Turgor: 2 seconds

A.Medical

Laboratory:
CT SCAN:
Impression: Reveals infarct Right Middle Cerebral Artery
ECG:
Impression: Atrial Fibrilation

Laboratory Results:

Complete Blood Count:

Hemoglobin = 150 g/L (120.00 -150.00 g/L)
Hematocrit = 45% (36%-45%)
RBC = 4.83 (4.10 - 5.10 x 10^6/uL)
MCV = 93.4 fL (80.00 - 100.00 fL)
MCH = 31.1 pg (28.00 - 33.00 pg)
MCHC = 33.3 g/dL (33.00 - 36.00 g/dL)
RDW - CV = 12.5% (12.00 - 15.00 %
WBC = 9.00X10^3/uL (4.40 - 11.30x10^3/uL)

Differential Count:
Segmenters = 55% (40 - 60%)
Lymphocyte = 29% (22.00 - 44.00%)
Monocyte = 7% (0.00-7.00%)
Eosinophils = 8 % (H) (0.00 - 4.00%)
Basophils = 1% (0.00 - 2.00%)
Platelet = 127x10^3u/L (150.00 - 450.00x10^3u/L)

Prothrombin Time (PT)

14 seconds (H) (10.90 - 13.40 seconds.)

Activated Partial Thromboplastin Time (aPTT)

22 seconds (21-35 seconds)

Serology Test
TSH = 3.33 uIU (0.27 - 4.20 uIU/mL)
FT3 = 11.64 pmol/L) (3.10 - 6.80 pmol/L)
FT4 = 11.64 pmol/L (L) (12.00 - 22.00 pmol/L)
RBS = 155.00 mg/dL (H) (80.00 - 140.00 mg/dL)
Creatinine = 0.99 mg/dL (H) (0.50 - 0.90 mg/dL)
BUN = 11.07 mg/dL (6.00 - 20.00 mg/dL)
Uric Acid = 5.60 mg/dL (2.40 - 5.70 mg/dL)

ALT/SGPT = 16.90 U/L (0.00 - 33.00 U/L)

Sodium = 142.00 mmol/L (135 - 145.00 mmol/L)

Potassium = 4.30 mmol/L (3.50 - 5.50 mmol/L)
Ionized Calcium = 1.23 mmol/L (1.00 - 1.30 mmol/L)

V. Management

A.Medical
1. Doctor’s order
-TPR q4 hours
-Sitting balance tolerance - Standing balance training
-Sit dangle to stand to ambulatory with quad arc.
-Deep breathing exercises
-Add simple hand and feet exercises

2. Recommended diet
- Eat in moderation as tolerated
- a wide variety of fruits and vegetables
- whole grains and products made up mostly of whole grains
- healthy sources of protein (mostly plants such as legumes and nuts; fish and seafood; low-fat or
nonfat dairy; and, if you eat meat and poultry, ensuring it is lean and unprocessed)
- liquid non-tropical vegetable oils
- minimally processed foods
- minimized intake of added sugars
- foods prepared with little or no salt
- limited or preferably no alcohol intake
●
3. Prescribed activity
- Avoid Strenous activity
-Do simple exercises that involves hands and feet

B. Nursing Interventions

VI. Discharge plan

Problem: Hypertension
DIET
Instruct client to restrict :
● Red meat
● Salt (sodium)
● Alcohol
● Food and drinks that contains added sugar

-Encourage client to do DASH DIET

DASH diet emphasizes foods that are lower in sodium as well as foods that are rich in potassium,
magnesium and calcium — nutrients that help lower blood pressure.

The DASH diet features menus with plenty of vegetables, fruits and low-fat dairy products, as
well as whole grains, fish, poultry and nuts. It offers limited portions of red meats, sweets and sugary
beverages.

Encourage the client to:

- Eat a diet rich in fruit , vegetables, and whole grain foods, as well as fish and skinless poultry
- Limit alcohol
- Increase their physical activity appropriate for her age
- Reduce the amount of sodium in their diet
- Manage stress
- Drink a lot of water
HYGIENE
HEAD ( hair , ears, teeth)
HEAD ( hair , ears, teeth)
● Hair
- Wash hair regularly. Massage your scalp well. This will remove dead skin cells, excess oil
and dirt. Rinse well with clear water.
● Teeth
- Brush at least twice a day for 2 minutes.
- Aim to brush after you wake up and before bed. If you can, brush after every meal too.
- Floss between your teeth daily
- Be gentle while brushing your teeth, if possible use a soft bristle toothbrush.
● Ears
- Don’t use cotton buds to clean your ears. They can irritate the ear canal and push wax
back inside, making it more difficult to remove.
- Don’t immerse your ears in bath water, as body bacteria may enter your ear canal and
could cause an infection
- Clean the outside of your ear with a damp cloth.
- You can use ear wax softener to soften earwax for easier removal
- Aim for no more than once a day until the excess wax is gone, but preferably only one or
two times a week.

HANDS
- Wet your hands with clean, running water (warm or cold), turn off the tap, and apply soap.
- Lather your hands by rubbing them together with the soap. Lather the backs of your hands,
between your fingers, and under your nails.
- Scrub your hands for at least 20 seconds.
- Rinse your hands well under clean, running water.
- Dry your hands using a clean towel or air dry them.

CLOTHING
- Changing used clothes for clean ones every day is recommended. Because bacteria builds up on
your clothes from sweat and nasty odor that comes from wearing the same pieces of clothing
too long.
- Wearing loose shirts ; not to get too hot .
- Wearing a hat or umbrella when going outside, especially when it's too hot is advised.

CLEAN SURROUNDINGS
- Clean house regularly. It will help client’s increase their physical activity
- Do not expose client to a very hot temperature; it can increase blood pressure .
- Changing linen and personal items.

ACTIVITY
- Rest as often as needed. Encourage the patient to have at least 8 hours of sleep.
- Avoid strenuous activities, such as minimizing the workload on her farm/pigsty.
 - Ask your family and friends to help with chores and errands.
- Avoid lifting anything over 10 pounds for 4 to 6 weeks.
- Walk as often as you feel able.

MEDICATIONS
- Propranolol 40 mg 1 tab ½ tab TID
- Losartan 50mg. 1 tab BID
- Cerebrolysin 10ml IVTT
- Cilostazo 50mg BID PO
- Warfarin ½ tab OD
- Pantoprazole 40 mg IVTT OD

COMMUNITY SUPPORT
- Instruct the client and significant others to go to the Barangay Health Center to avail services
that they offer for the continuous monitoring of client's condition.
- Instruct client and significant other to keep a record of telephone or mobile numbers of the
doctor, family, members, neighbors, and health agencies in case of emergency.

SPIRITUAL
- Respect client’s beliefs
- Encourage the family to pray together with the client
- Encourage the family to lengthen their patience when dealing with the client.

FINANCIAL RESOURCES & NEEDS

- Make sure that the patient settle his account before discharge
- Encourage the client to avail the program of the government such as PhilHealth,PCSO and other
health insurance.

APPOINTMENT
Visit the Physician
WHEN: April 7, 2023 ; 8 AM
WHERE: Metro Bacolod Hospital and Medical Center
Purpose: Follow up check up

PROBLEM LEVELS OF CARE HEALTH TEACHINGS

Promotive ● Eat a diet rich in fruit ,

vegetables, and whole
 grain foods, as well as
fish and skinless poultry

Avoid strenuous
activities
Rest as often as needed.

Preventive
Call your doctor or nurse call
Increased Blood Pressure line now or seek immediate
medical care if:

● Blood pressure will

increase.
● Difficulty of breathing

Curative ● Take the medication as

ordered by the
physician.

Rehabilitative ● Comply the follow up

check up to monitor the
condition.

PROBLEM LEVELS OF CARE HEALTH TEACHINGS

Promotive ● Include protein to the

diet to help strengthen
muscles.
● Allow patient to do
resistance exercises for
strengthening muscles.
● Rest as needed

Preventive ● Avoid strenuous

activities
● Assist patient with ADL
Left sided body weakness
● Do not strain the muscle
of the affected side

Curative ● Take over the counter

and prescription
medicines as told by
 your health care
provider

Rehabilitative ● Emphasize all the follow

up visits since this is
important.
● Encourage working with
a physical therapist who
can develop an exercise
plan to help you gain
muscle strength

PROBLEM LEVELS OF CARE HEALTH TEACHINGS

Promotive ● Emphasize the DASH

diet needs to be strictly
follow
● Encourage compliance
of eating healthy

Preventive ● Prioritize the positive

aspects of healthy
eating rather than
focusing on unhealthy
eating.
● Reinforce healthy habits
Unhealthy eating habits and be patient with
yourself.

Curative ● Show compliance and

commitment in
eradicating unhealthy
eating habits by taking
medications provided
by the physician.

Rehabilitative ● Seek for help or

assistance to a dietician
to further reassess and
provide another sets of
options.

VII. Evaluation
1. Patient's progress:
- Patient blood pressure slightly decreased
 "Daw mayo naman pamatyagan ya" as verbalized by the significant others.

BP: 140/80

2. After 24 hours of duty we were able to meet our objectives for this case study as evidenced by:
- We conducted an interview thoroughly.
- Developed an organized case presentation.
- Established an interview with respect and rapport was manifested.

VIII. Reference:
American Heart Association. (2016). How High Blood Pressure Can Lead to Stroke. Www.heart.org.http
s://www.heart.org/en/health-topics/high-blood-pressure/health -threats-from-high-blood-pressure/
how-high-blood-pressure-can-lead-to-stroke

Deglin, Judith Hopfer, & Vallerand, April Hazard (2007). Davis’s Drug Guide for Nurses 10th edition.
Pennsylvania. F.A Davis Company.

Hinkle, Janice L., Kerry H., Cheever and Janice L. Hinkle (2018) .Brunner & Suddarth's textbook of
medical-surgical nursing. 14th edition. Philadelphia: Wolters Kluwer. Chicago / Turabian

Varounis, C., Katsi, V., Nihoyannopoulos, P., Lekakis, J., & Tousoulis, D. (2017). Cardiovascular
hypertensive crisis: recent evidence and review of the literature. Frontiers in cardiovascular medicine, 3,
51.