I.

Introduction
A stroke is a cerebrovascular accident, or what is now being termed as ―Brain attack‖ is a sudden loss of brain function resulting from disruption of blood supply to a part of the brain resulting from pathologic blood vessels. It denotes an abnormality of the brain. Stroke can be classified into Ischemic and Hemorrhagic strokes. Ischemic stroke can be divided into thrombotic and embolic stroke. Thrombotic stroke results from the narrowing or occlusion of blood vessels from a blood clot originating from the other parts of the body most commonly from the heart. In the Philippines, it is the most common with 70% of cases. In addition, Bader and Littlejohns (2004) stated that hemorrhagic stroke accounts for 15% to 20% of cerebrovascular disorder and it was further classified into intracerebral hemorrhage and subarachnoid hemorrhage. Hemorrhagic strokes are caused by bleeding into the brain tissue, the ventricles or the subarachnoid space. Primary intracerebral hemorrhage from a spontaneous rupture of a small vessels accounts for approximately 80% of hemorrhagic strokes and is caused chiefly by uncontrolled hypertension, atherosclerosis and cerebral amyloud angiopathy. Secondary intracerebral hemorrhage is associated with arteriovenous malformation (AVMs) intracranial aneurysm, intracranial neoplasms or certain medications. In addition, Smeltzer, et. Al (2008) enumerated that advanced age, gender, and race are well – known nonmodifiable risk factors for stroke. Modifiable risk factors for hemorrhagic stroke include hypertension, hyperlipidemia, obesity, smoking and diabetes. According to Smeltzer and Bare, (2004) hemorrhagic stroke can present with a wide variety of neurologic deficits, similar to a patient with ischemic stroke. The conscious patient mostly common reports a severe headache, vomiting, an early sudden change in level of consciousness, there may be visual disturbances (visual loss, diplopia, ptosis), motor deficits (hemiparesis, hemiplegia, ataxia, dysarthria, dysphagia) sensory deficits (paresthesia), verbal deficits (expressive aphasia, receptive aphasia, global aphasia), cognitive deficits and emotional deficits. To assess the client with hemorrhagic stroke, some diagnostic exams were needed to perform. Any patient with suspected stroke should undergo CT scan to determine the type of stroke and the size and location of hematoma. Lumbar puncture is performed if there is no evidenced of increased ICP, the CT scan results are negative and subarachnoid hemorrhage must be confirmed. Moreover, Mayer, Brun, Begtrup, et. Al (2005) cited the goals of medical treatment for hemorrhagic stroke are to allow the brain to recover from the initial attack (bleeding), to prevent or minimize the risk for rebleeding, and to prevent or treat complications. Management is primarily supportive and consists of bed rest with sedation to prevent agitation and stress. Analgesics (codeine, acetaminophen) may be prescribed for head and neck pain. In addition, treatment of intracerebral hemorrhage differs from that of an ischemic stroke. Anticoagulants (such as heparin and warfarin). Thrombolytic drugs and antiplatelet drugs (such as aspirin) are

not given because they make bleeding worse. If people who are taking an anticoagulant have a hemorrhagic stroke, they may need a treatment that helps blood clot such as; Vitamin K, usually given intravenously, Transfusions of platelets, Transfusions of blood that has had blood cells and platelets removed (fresh frozen plasma), Intravenous administration of a synthetic product similar to the proteins in blood that help blood to clot (clotting factors). According to Hickey (2003), surgical evacuation is most frequently accomplished via craniotomy. Morbidity and mortality from surgery are high if the patient is sturporous or comatose. Surgical treatment of the patient with an unruptured aneurysm is an option. The goal o surgery is to prevent bleeding in an unruptured aneurysm. Moreover, Black and Hawkes (2008) cited that client education is aimed at stroke prevention. Primary prevention of stroke includes the following: maintaining safe cholesterol levels, smoking cessation; using low – dose estrogen contraceptives only in the absence of other risk factors, reducing alcohol consumption, and eliminating illicit drug use. Secondary prevention includes the following: adequate blood pressure control; care of diabetes mellitus, and treatment of cardiovascular disease, TIA, and atrial fibrillation. Prognosis depends on the neurologic condition of the patient, the patient’s age, associated disease, and the extent and location of the hemorrhage or intracranial aneurysm. Subarachnoid hemorrhage is a catastrophic event with significant morbidity and mortality. The primary concern of this study is to further enhance the understanding of CVA accident in congruence with the learned concepts of the nursing students. This case study emphasizes detailed assessment of the subject as a whole. It determines the past history, present history of illness, social history and family history as these may affect overall health. Furthermore, this study examines the self – care practices that the patient observed in maintenance of this health. Likewise, it reviews the ways in which the patient addresses/satisfies her physiologic needs as nutrition, activity, sleep, fecal and urinary elimination, and hygiene.

II.PATIENT PROFILE/PERSONAL DATA
Name: Age: Address: Birth date: Place of Birth: Sex: Civil Status: Nationality: Religion: Chief Complaint: Date of admission: Time of Admission: Admitting Physician: Clinical Impression: Mrs. R.I.E. 81 years old Poblacion, Morong, Bataan June 18, 1949 Bicol Female Married Filipino Roman Catholic Right Sided body weakness 1 day prior to admission August 18, 2011 1:50 p.m Dra.Guttierez Stroke secondary to HPN.

III.PERSONAL-SOCIAL HISTORY
The client always wants to eats salty foods like snacks, noodles, fatty foods like chicharon baboy and also she wants to eat meat foods and fish. She is also a smoker and she started to smoke at the age of 25, and she spends 3 stick of cigarettes per day, but she stopped smoke at the age of 65.She usually sleep on time and she sleep for about 6-8 hours. She has 8 siblings, 5 males and 3 females and the 2 female’s works as a helper in some of their relatives to support their family. According to her daughter, they have a good family relationship. She did not enter high school and college and she only enter grade 1 and she need to stop because of financial problem. She works as a helper in their relatives and she usually walks going to her work but at the age of 60 she stopped working because of her condition. As stated by her daughter, their life is quiet hard, because the money that they earn is not sufficient for their everyday lives. According to her daughter their residence is compound-like and near from the beach, some of their neighbor is their relatives and some are friends. They don’t have any problems in their neighbors in terms of relationship.

IV. Past Medical History
Her sixth daughter, Mrs. C.E states that her mother who is Mrs. R.E (the patient) had suffered from radiating pelvic pain since the end of year 2004. Due to the recurrent pain felt in the pelic area and during urination, Mrs. R.E had her medical check ups to Dr. Bustamante and it results to UTI. The first check-up was done on March 16,2005 followed by her second checkup on April 16, 2004 still due to UTI. She was been instructed to take Ciprofloxacin 500mg tab B.I.D for her UTIandNicardipine capsule T.I.D after finding out of elevated BP. These medications were discontinued immediately due to their financial crisis. Also, her daughter claimed that Mrs. R.E doesn’t have any vitamins maintainance and had never gone confinement due to hypertension.

V. Present Medical History

Admitted at Bataan Provincial Hospital last August 18, 2011 at 1:50 pm with a chief complaint of Right body weakness. Few hours PTA, according to her daughter, Mrs. R.E suffered from severe headache and dizziness and she fall upon standing due to the complain of blurring of vision. Mrs. R.E’s daughter rushed her to hospital (BPH) and she was been confined with a admitting diagnosis of CVA broad vs. infection with a initial vital signs of: BP:200/100, Temp:35.4 , PR:52, RR:38 . She was requested for CBC, Na, K, BUN, Creatinine, ABG, Lipid profile, U/A and CXR. The results on her creatinine and BUN shows in increase level. For CXR, it shows cardiomegaly with mild pulmonary congestion. On her CBC results, the hematocrit and hemoglobin count also decreases while the WBC increases. During her hospitalization, medications have been administered as follows: Mannitol, citicholine, Ciprofloxacin, Paracetamol, Diazepam and combivent nebulizer.

FAMILY HISTORY (GENOGRAM) 75 HTN 60 HTN 81 CVA 65 CVA 53 CVA 76 71 CVA 73 CVA 71 68 57 56 55 53 49 47 44 29 Hepa B 41 40 LEGENDS: =Alive Female =Alive Male =Deceased Male =Deceased Female .VI.

and liempo. She sleeps at night at 9 o'clock then woke up in the morning at 5 o'clock. When her daughter tends to feed her.  Sleep and rest  Elimination STOOL: PTA he usually STOOL: she did not defecates once a day. When she was confined. She has a regular pattern of sleeping. Within the day she is sleeping for about 15 hours. During hospitalization In her confinement. she is not able to eat anything. meat such as pork. fatty foods such as chicharon baboy. difficulty of breathing and severe body malaise. He is not eliminate for his whole also constipated. she usually vomits. she is frequently sleeping. due to paralysis of the right side of the body. She had a sedentary exercise due to paralysis lifestyle. She also takes a nap for 2-3 hours. catheter connected to a urine bag. confinement. and unable to ambulate. her urine is URINE: she has a foley hazy. 3 sticks a day then extra activities now due to stopped at the age of 65 years paralysis old . She also fonds of eating sweets such as candies and chocolates.  Activities She had been a smoker since She cannot perform any 25 years old.VIII. Within an hour her urine is 30ml. PATTERNS OF DAILY LIVING Activity  Nutrition Before hospitalization She usually eats salty foods such as canned goods and noodles. URINE: she frequently urinates 10 times a day.  Exercise She is not active in any form of She is not engage in any exercise.

Loss of dermis and subcutaneous fats. 2011 200/100mmHg 35. PHYSICAL ASSESSMENT Vital signs BP Temp PR RR August 23. Due to aging Normal   Pale noted Appears thin and translucent When pinched. skin springs back slowly to previous state Mixture of black and white in color hair Free from infestation and alopecia Lighter in color than the complexion Moist No scars No lesions Free from lice and dandruff No tenderness and masses    Palpation Hair Inspection         Palpation          Palpation Scalp Inspection Normal Normal Normal Normal Normal Normal . normal with aging Due to decrease oxygen supply in the body. Decrease elasticity of the skin due to aging.4C 52bpm 38cpm Body parts Skin Technique Inspection Findings   Brown shade black Dry. flaky to Interpretation   Normal Sebaceous and sweat glands are less active. normal with aging.IX.

Skull Inspection Palpation      Normocephalic No tenderness upon palpation Shape: oval Positive peripheral facial drooping Paralysis of the right side of the face. Normal Due to paralysis and generalized body weakness. Normal Face Inspection Eyes Inspection                       Eyebrows Inspection    Symmetrical and in line with others Black in color Evenly distributed Black in color Evenly distributed Turned outward Symmetrical PTOSIS note Meets completely when the eyes are closed Non palpable No tenderness Pale in color Moist No ulcers No foreign objects With presence of capillaries Anicteric Some capillaries are visible Eyelashes Inspection Eyelids Inspection              Lacrimal apparatus Conjunctiva Palpation Normal Normal Abnormal due to decreased oxygen perfusion Normal Normal Normal Normal Normal Normal Inspection Sclera Inspection   . Normal Normal Normal Normal Normal Normal Normal Due to paralysis of the right side of the body. Evenly placed and symmetrical with each other Usually shut      Normal Normal Normal Due to paralysis Due to a lesion in the opposite cerebral hemisphere.

normal with aging Normal Ears Inspection Palpation   Nose Inspection     Palpation Nasal mucosa Inspection Palpation Mouth (lips) Inspection        .Cornea Pupils Inspection Inspection            Looks smooth Clear Sluggish Non reactive to light and accomodation Black in color E ar lobes are bean shaped Parallel with each other Symmetrical Skin is the same in color in the complexion No lesions noted on inspection Auricles has a firm cartilage The pinna recoils when folded No pain and tenderness In the midline No discharges Both nares are patent with flaring of nostrils no tenderness pale in color no tenderness drooping pale in color noted dry no edema                         Normal Normal Abnormal. Due to damage on cranial nerve:optic Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Due to difficulty of breathing normal Due to decrease blood perfusion Normal Due to paralysis of the right side of the body Due to decrease oxygen supply Decreased salivary gland activity. due to decreased oxygen perfusion.

Normal Due to decrease oxygen supply normal      Neck Inspection     Trachea Palpation   Palpation Uvula Inspection Tongue is retracted with thick mucus. surface of tongue is rough positioning in the midline pale no swelling lesion noted or            neck is straight no visible mass or lumps symmetrical veins are not distended Trachea is palpable Positioned in the midline and normal normal normal normal Normal Normal .Palpation  Gums Inspection       no pain/ tenderness on palpation and during jaw movement pale noted no bleeding noted all teeth are loss no halitosis Pale keep moist saliva by  Normal           Teeth Buccal mucosa Inspection Inspection Due to decrease oxygen supply normal Due to aging Normal Due to decrease oxygen supply Normal Tongue Inspection     pale with white taste buds no lesions noted no varicosities on ventral surface gag reflex absent Due to decrease oxygen supply Normal Normal Due to motor and sensory dysfunction Compression of cranial nerves and brain tissue Due to decrease production of saliva. Unable to move.

due to decreased oxygen perfusion Abnormal due to altered circulation Abnormal due to reduced peripheral circulation Due to paralyzed muscles which result in decreased active muscle pump for removing excess fluid Lungs Auscultation  Heart Inspection    RR: 38cpm Apical pulse is not visible No heaves and thrills PR: 52bpm     Abdomen Inspection Auscultation Palpation      No lesions/ scars noted Decrease bowel sounds No tenderness Pale Cold to touch Capillary refill > 3 seconds With pitting edema        Upper extremities Inspection Palpation   . due to fluid accumulation in the lungs.Lymph nodes Thyroid Chest Palpation Palpation Inspection       straight Non tender Slightly movable Non palpable Symmetrical Use of accessory muscle With crackle breath sounds on both lungs       Normal Normal Normal Normal Abnormal. Due to difficulty of breathing Normal Normal Due to decrease cardiac tissue perfusion and cardiomegaly Normal Abnormal. pulmonary congestion. due to constipation Normal Abnormal. due to increased oxygen demand Abnormal.

sign of thrombophlebitis Due to immobility Genital Inspection  With IFC  .Lower extremities Inspection     Pale Cold to touch Capillary refill > 3 seconds With pitting edema     Palpation  Positive sign homan's  Abnormal. due to decreased oxygen perfusion Abnormal due to altered circulation Abnormal due to reduced peripheral circulation Due to paralyzed muscles which result in decreased active muscle pump for removing excess fluid Due to clotting of blood in the valves of deep calf veins.

Glascgow Coma Scale 4 3 2 1 6 5 4 3 2 1 5 4 3 2 1 08-23-11 Best eye opening Spontaneous To speech To pain None Best motor response Obeys command Localizes pain Withdraw Decorticate Decerebrate None Best verbal response Oriented Confuse speech Inappropriate Incomprehen sible None Total Sensorium Awake Drowsy Stuporous Comatose Vegetative 8 9 10 11 12 1 2 3 4 5 6 7                          8   8   8   8   8   8   8   8   8   8   8   8  .

4C 60bpm 35cpm Body parts Skin Technique Inspection Findings   Brown shade black Dry. normal with aging. flaky to Interpretation   Normal Sebaceous and sweat glands are less active.PHYSICAL ASSESSMENT Vital signs BP Temp PR RR August 24. 2011 180/110mmHg 37. Loss of dermis and subcutaneous fats. Decrease elasticity of the skin due to aging. skin springs back slowly to previous state Mixture of black and white in color hair Free from infestation and alopecia Lighter in color than the complexion Moist No scars No lesions Free from lice and dandruff No tenderness and masses    Palpation Hair Inspection         Palpation          Palpation Scalp Inspection Normal Normal Normal Normal Normal Normal . Due to aging Normal   Pale noted Appears thin and translucent When pinched. normal with aging Due to decrease oxygen supply in the body.

Evenly placed and symmetrical with each other Usually shut      Normal Normal Normal Due to paralysis Due to a lesion in the opposite cerebral hemisphere. Normal Normal Normal Normal Normal Normal Normal Due to paralysis of the right side of the body. Normal Face Inspection Eyes Inspection                       Eyebrows Inspection    Symmetrical and in line with others Black in color Evenly distributed Black in color Evenly distributed Turned outward Symmetrical PTOSIS note Meets completely when the eyes are closed Non palpable No tenderness Pale in color Moist No ulcers No foreign objects With presence of capillaries Anicteric Some capillaries are visible Eyelashes Inspection Eyelids Inspection              Lacrimal apparatus Conjunctiva Palpation Normal Normal Abnormal due to decreased oxygen perfusion Normal Normal Normal Normal Normal Normal Inspection Sclera Inspection   . Normal Due to paralysis and generalized body weakness.Skull Inspection Palpation      Normocephalic No tenderness upon palpation Shape: oval Positive peripheral facial drooping Paralysis of the right side of the face.

Cornea Pupils Inspection Inspection            Looks smooth Clear Sluggish Non reactive to light and accomodation Black in color E ar lobes are bean shaped Parallel with each other Symmetrical Skin is the same in color in the complexion No lesions noted on inspection Auricles has a firm cartilage The pinna recoils when folded No pain and tenderness In the midline No discharges Both nares are patent with flaring of nostrils no tenderness pale in color no tenderness drooping pale in color noted dry no edema                         Normal Normal Abnormal. Due to damage on cranial nerve:optic Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Due to difficulty of breathing normal Due to decrease blood perfusion Normal Due to paralysis of the right side of the body Due to decrease oxygen supply Decreased salivary gland activity. due to decreased oxygen perfusion. normal with aging Normal Ears Inspection Palpation   Nose Inspection     Palpation Nasal mucosa Inspection Palpation Mouth (lips) Inspection        .

Normal Due to decrease oxygen supply normal      Neck Inspection     Trachea Palpation   Palpation Uvula Inspection Tongue is retracted with thick mucus. Unable to move.Palpation  Gums Inspection       no pain/ tenderness on palpation and during jaw movement pale noted no bleeding noted all teeth are loss no halitosis Pale keep moist saliva by  Normal           Teeth Buccal mucosa Inspection Inspection Due to decrease oxygen supply normal Due to aging Normal Due to decrease oxygen supply Normal Tongue Inspection     pale with white taste buds no lesions noted no varicosities on ventral surface gag reflex absent Due to decrease oxygen supply Normal Normal Due to motor and sensory dysfunction Compression of cranial nerves and brain tissue Due to decrease production of saliva. surface of tongue is rough positioning in the midline pale no swelling lesion noted or            neck is straight no visible mass or lumps symmetrical veins are not distended Trachea is palpable Positioned in the midline and normal normal normal normal Normal Normal .

Due to difficulty of breathing Normal Normal Due to decrease cardiac tissue perfusion and cardiomegaly Normal Abnormal. pulmonary congestion.Lymph nodes Thyroid Chest Palpation Palpation Inspection       straight Non tender Slightly movable Non palpable Symmetrical Use of accessory muscle With crackle breath sounds on both lungs       Normal Normal Normal Normal Abnormal. due to constipation Normal Abnormal. due to fluid accumulation in the lungs. due to increased oxygen demand Abnormal. due to decreased oxygen perfusion Abnormal due to altered circulation Abnormal due to reduced peripheral circulation Due to paralyzed muscles which result in decreased active muscle pump for removing excess fluid Lungs Auscultation  Heart Inspection    RR: 38cpm Apical pulse is not visible No heaves and thrills PR: 52bpm     Abdomen Inspection Auscultation Palpation      No lesions/ scars noted Decrease bowel sounds No tenderness Pale Cold to touch Capillary refill > 3 seconds With pitting edema        Upper extremities Inspection Palpation   .

sign of thrombophlebitis Due to immobility Genital Body parts Skin Inspection Technique Inspection  With IFC  Findings   Brown shade black Dry. normal with aging.Lower extremities Inspection     Pale Cold to touch Capillary refill > 3 seconds With pitting edema     Palpation  Positive sign homan's  Abnormal. flaky to Interpretation   Normal Sebaceous and sweat glands are less active. due to decreased oxygen perfusion Abnormal due to altered circulation Abnormal due to reduced peripheral circulation Due to paralyzed muscles which result in decreased active muscle pump for removing excess fluid Due to clotting of blood in the valves of deep calf veins. normal with aging Due to decrease oxygen supply in the body. Loss of dermis and subcutaneous fats. Decrease elasticity of the skin due to aging. .   Pale noted   Appears thin and translucent   When pinched.

Normal Eyes Inspection  Evenly placed and symmetrical with  .skin springs back slowly to previous state Palpation Hair Inspection         Palpation Scalp Inspection Mixture of black and white in color hair Free from infestation and alopecia Lighter in color than the complexion Moist No scars No lesions Free from lice and dandruff No tenderness and masses  Due to aging   Normal Normal      Normal Normal Normal Normal Normal Palpation Skull Inspection Palpation Face Inspection      Normocephalic No tenderness upon palpation Shape: oval Positive peripheral facial drooping Paralysis of the right side of the face.      Normal Normal Normal Due to paralysis Due to a lesion in the opposite cerebral hemisphere.

Eyebrows Inspection         Symmetrical and in line with others Black in color Evenly distributed          Normal Normal Normal Normal Normal Normal Normal Due to paralysis of the right side of the body. Normal Eyelashes Inspection Eyelids Inspection Black in color Evenly distributed Turned outward Symmetrical PTOSIS noted     Lacrimal apparatus Conjunctiva Palpation Meets completely when the eyes are closed Non palpable No tenderness Pale in color    Normal Normal Abnormal due to decreased oxygen perfusion Normal Normal Normal Normal Normal Normal Inspection      Sclera Inspection   Moist No ulcers No foreign objects With presence of capillaries Anicteric Some capillaries are visible      . each other Usually shut  Due to paralysis and generalized body weakness.

due to decreased oxygen perfusion. Due to damage on cranial nerve:optic           Ears Inspection Non reactive to light and accomodation Black in color E ar lobes are bean shaped Parallel with each other Symmetrical Skin is the same in color in the complexion No lesions noted on inspection Auricles has a firm cartilage The pinna recoils when folded No pain and tenderness    Normal Normal Normal   Normal Normal   Normal Normal Palpation  Normal Nose Inspection     In the midline No discharges Both nares are patent with flaring of     Normal Normal Normal Normal .Cornea Pupils Inspection Inspection    Looks smooth Clear Sluggish     Normal Normal Abnormal.

normal with aging Normal Normal   Due to decrease blood perfusion Normal Palpation Mouth (lips) Inspection   Gums Inspection   no edema no pain/ tenderness on palpation and during jaw movement pale noted no bleeding noted all teeth are loss no halitosis pale       Due to decrease oxygen supply normal Teeth Buccal mucosa Inspection Inspection    Due to aging Normal Due to decrease oxygen supply Normal . nostrils no tenderness   Due to difficulty of breathing normal Palpation Nasal mucosa Inspection    pale in color no tenderness drooping    Palpation  pale in color noted dry    Due to paralysis of the right side of the body Due to decrease oxygen supply Decreased salivary gland activity.

surface of tongue is rough   Palpation Uvula Inspection    positioning in the midline pale no swelling lesion noted or          Neck Inspection     neck is straight no visible mass or lumps symmetrical veins are not distended Trachea is palpable Positioned in the midline and straight normal normal normal normal Normal Normal Trachea Palpation   . Unable to move. Tongue Inspection     keep moist by saliva pale with white taste buds no lesions noted no varicosities on ventral surface gag reflex absent     Due to decrease oxygen supply Normal Normal Due to motor and sensory dysfunction Compression of cranial nerves and brain tissue Due to decrease production of saliva. Normal Due to decrease oxygen supply normal   Tongue is retracted with thick mucus.

pulmonary congestion. due to decreased oxygen perfusion Abnormal due to altered circulation Abnormal due to reduced peripheral circulation . due to increased oxygen demand Abnormal. due to constipation Normal Palpation Upper extremities Inspection  Pale   Palpation   Cold to touch Capillary refill > 3  Abnormal.Lymph nodes Thyroid Chest Palpation Palpation Inspection       Non tender Slightly movable Non palpable Symmetrical Use of accessory muscle With crackle breath sounds on both lungs       Normal Normal Normal Normal Abnormal. due to fluid accumulation in the lungs. Due to difficulty of breathing Normal Normal Lungs Auscultation      RR: 38cpm Apical pulse is not visible No heaves and thrills PR: 52bpm Heart Inspection    Abdomen Inspection   Auscultation  No lesions/ scars noted Decrease bowel sounds No tenderness    Due to decrease cardiac tissue perfusion and cardiomegaly Normal Abnormal.

seconds   With pitting edema Due to paralyzed muscles which result in decreased active muscle pump for removing excess fluid Lower extremities Inspection  Pale     Cold to touch Capillary refill > 3 seconds    With pitting edema  Abnormal. due to decreased oxygen perfusion Abnormal due to altered circulation Abnormal due to reduced peripheral circulation Due to paralyzed muscles which result in decreased active muscle pump for removing excess fluid Due to clotting of blood in the valves of deep calf veins. sign of thrombophlebitis  Genital Inspection  Positive homan's sign With IFC  Due to immobility .

Glascgow Coma Scale 4 3 2 1 6 5 4 3 2 1 5 4 3 2 1 08-24-11 Best eye opening Spontaneous To speech To pain None Best motor response Obeys command Localizes pain Withdraw Decorticate Decerebrate None Best verbal response Oriented Confuse speech Inappropriate Incomprehen sible None Total Sensorium Awake Drowsy Stuporous Comatose Vegetative 8 9 10 11 12 1 2 3 4 5 6 7                          7  7  7  7  7  7  7  8   8   8   8   8         .

Indicates risk for heart attack and stroke.35 WBC 5.7mmol/L TRIGLYCERIDES 0. Indicates decreased kidney function.5mmol/L Interpretation Indicates normal kidney excretion.0mmolL Hematologic report Date: 8-19-11 Components CBC HEMOGLOBIN Normal value 120-150g/l Results 102g/l Interpretation The normal oxygen carrying capacity of the blood.0 x 10 g/L 6.25-0.1 x 10 g/L . Indicates capacity.5-7.8-1. CREATININE 0.2mmol/L 149.37-0. Has normal pack of RBC/blood viscosity. LABORATORIES/DIAGNOSTIC PROCEDURES Blood chemistry Date: 8-19-11 Component BUN Normal value Result 62-120mmol/L 2.X.46-1. Due to UTI increase WBC HEMATOCRIT 0.31 LYMPHOCYTES 0.9 1.47 0.7mmol/L CHOLESTEROL <6. Has normal level of triglycerides to be used as energy of the body.40 0.5 4.

diaphragm & sinuses are negative . Aorta is sclerotic degenerative changes of the thoracic spine.X-ray X-ray/utz no: 180638 Name of pt: E. 2011 Age: 81 Sex: F Type of examination: x-ray Part examined: chest PA Interpretation: cardiomegaly with pulmonary congestion.R Date: Aug 15.

E nutrition. SELF CARE AGENCY. . prevention of hazards.E perform self care. activity/rest. R. R. Also Mrs. air. bathing . NURSING AGENCY nurses who workede for Mrs. maintain a developmental environment. grooming and oral hygiene.E ant the measures carried out by the nurtse to meet self care requisites. UNIVERSAL SELF CARE REQUISITES for drainage. elimination. food . THEORETICAL FRAMEWORK APPLICATION OF THE THEORY FOR MRS. R. adjust lifestyle to accomodate the health status changes and medical regimen.E that need assisitance. activity. Mrs R.E has an IFC connected to urine bag HEALTH DEVIATION SELF CARE ACTIVITIES these includes the needs of Mrs. SELF CARE REQUISITES these are the need of Mrs.E composed the nursing agency. R.E SELF CARE – this are the activities of daily living which Mrs. For her urionation he has an IFC to aid in her urination. fecal and urinary elimination. Nursing systems are those actions listed nursing care plan.E dependent care agent during hospitalization was the nurse and his rlatives. dressing . THERAPEUTIC SELF CARE DEMAND these are the deficient areas of Mrs. SELF CARE DEFICIT. These listed the independent actions of the nurse and how the client can cooperate to meet his self care therapeutic demand.E patterns of daily living. R. Mrs. NURSING SYSTEMS. Mrs R. In Mrs R. maintenance of health status. water.XI. R.E is the agent DEPENDENT CARE AGENT . R. she is independent in performing activities such as .E ability to perform self care describe her self care agency AGENT. R. rest and hygiene.

is electrical impulses which are rapid and specific and cause almost immediate responses. They link all parts of the body by carrying impulses from the sensory receptors to the CNS and from the PNS to the appropriate glands or muscles. To carry out its normal role the nervous system has three overlapping functions: 1. It divides into two principle subdivisions. Its signaling device. These nerves serve as communication lines. action and emotion reflects its activity. 2. it uses its millions of sensory receptors to monitor changes occurring both inside and outside the body. The CNSconsists of the brain and spinal cord. It processes and interprets the sensory inputs and makes decisions what should be done at each moment a process called integration. ANATOMY AND PHYSIOLOGY NERVOUS SYSTEM The nervous system is the master controlling and communicating system of the body. . or means of communicating with body cells. While the nervous system controls with rapid electrical nerve impulses. Thus the endocrine system typically brings about its effect in a more leisurely way. FUNCTIONAL CLASSIFICATION The functional classification scheme is concerned only with PNS structures. the endocrine system is the second important regulating system. It then affects a responds by activating muscles or glands via motor output. The PNS the part of the nervous system outside the CNS consist mainly of the nerves that extend from the brain and the spinal cord. which occupy the dorsal body cavity and acts as the integrating and command centers of the nervous system. Every thought.XII. STRUCTURAL CLASSIFICATION The structural classification which includes all nervous system organs has two subdivisions. the Central Nervous Systemand the Peripheral Nervous System. The interpret incoming sensory information and issue instructions based on past experiences and current conditions. The nervous system does not work alone to regulate and maintain body homeostasis. These changes are called stimuli and gathered information is called sensory input. Spinal nerves carry Impulses to and from spinal cord. 3. the endocrine system organs produce hormones that are release into the blood. Cranial nerves carry impulses to and from the brain. Much like a sensory.

However. or involuntary. controls our skeletal muscles. they effect (bring about) a motor response. or voluntarily. each of the different types of neuroglia also simply called glia or glial cells. Skeletal muscle reflexes like the stretch reflex for example. including dead brain cells and bacteria. this subdivision is often referred to us the voluntary nervous system. Sensory fibers delivering impulses from the skin. The sensory division keeps the CNS constantly informed of events going on both inside and outside of the body. Microglia: spiderlike phagocytes that dispose of debris. they helpprotects the neurons from harmful substances that might be in the blood. Astrocytes also help control the chemical environments in the brain by picking up excess ions and recapturing released neurotransmitter. are initiated in voluntarily by these same fibers. The beating of their cilia helps to circulate the cerebrospinal fluid that fills those cavities and forms a protective cushion around that CNS. Their numerous projections have swollen ends that cling to neurons. The autonomic nervous system regulates events that are autonomic. This subdivisions commonly called the Involuntary Nervous System. In additions. consists of nerve fibers that convey impulses to the CNS from sensory receptors located in various parts of the body. The motor or efferent division carries impulses from CNS to effector organs. Astrocytes from a living barrier between capillaries and neurons and play a role in making exchanges between the two. The somatic nervous system allows us to consciously.   . SUPPORTING CELLS Supporting cells in the CNS are “lump together” as neuroglia. “nerve glue”. the muscles and glands. the sympathetic and parasympathetic. which typically brings about opposite effects. bracing them and anchoring them to their nutrient supply lines.The sensory or afferent divisions. skeletal muscles and joint calledsomatic sensoryfibers or visceral afferents. Hence. the blood capillaries. The motor division in turns has two subdivisions: 1. This impulses activate muscles and glands. insulate and delicate neurons. Ependymal cells: these glial cells line the cavities of the brain and the spinal cord.Neuroglia includes many types of cells that generally supports. In this way. 2. has special functions. not all skeletal muscles activity controlled by this motor division is voluntary. The CNS glia includes:  Astrocytes: abundant star-shaped cells that account for nearly half of the neural tissues. such as the activity of smooth and cardiac muscles and glands. that is. literally. itself has two parts.

THE CENTRAL NERVOUS SYSTEM  Spinal cord The spinal cord runs from the base of the skull all the way down in the spine to the ―tail bone‖. Although neurons differ structurally. Consequently. they have many common features. producing fatty insulating coverings called myelin sheaths. glia are not able to transmit nerve impulses. cushioning cells. All have a cell body. Supporting cells in PNS come in two major varieties – Schwann cells and satellite cells. Schwann cells form the myelin sheaths around nerve fibers that are found in the PNS. Another important difference is that glia nerve loses their ability to divide. There are motor pathways going up to the brain . Although they somewhat resemble neurons structurally. most brain tumors are gliomas or tumors formed by glial cells (neuroglia). a function that is highly developed in neurons. which contain the nucleus and is the metabolic center of the cell. The neurons are found in an H-shaped space within the spinal vertebrae. are highly specialized to transmit messages (nerve impulses) from one part of the body to another. Satellitecells acts as protective. NEURONS Neurons. also called nerve cells. and one or more slender processes extending from the cell body. whereas most neurons do. Oligodendrocytes: glia that wraps their flat extensions tightly around the nerve fibers.

and the forebrain. like a part in your hair. the hindbrain the midbrain. . This drawing is roughly what it would look like if you sliced your brain straight down the middle. Brain The brain is traditionally divided into three parts. the back on the right. The front of the brain is on the left.

The cerebellum. when you learn complex motor tasks. which is called the cerebellum. It starts with the thalamuswhich is practically in the center of your head. is in fact shaped like a small brain. containing tracts up and down to and from the higher portions of the brain. It is primarily the pathways connecting the two halves of the next part. The largest and. . It is the regulatory system for sleep. it connects the midbrain to the forebrain. which means “little brain” in Latin. The first is the medulla. It is much larger in lower animals and in the human fetus. in human beings. The thalamus is like a switching station. The midbrain is. in fact. It is believed that. Besides. and it’s primarily responsible for coordinating involuntary movement. which means bridge in Latin. The fore brain though is complex enough to require its own chapter—two. The upper part of the medulla contains a pinky-sized complex of nuclei called reticular formation. the details are recorded in the cerebellum.The hindbrain is brain stem consists of three parts. and wraps around it to back. and one for the cerebrum. the smallest part of the brain. walking and alertness. the medulla also contains some of the essential nuclei that govern respiration and heart rate. which is actually an extension of the spinal cord into the skull. and down from the brain to the lower brain and spinal cord. and contains several pathways important to hearing and vision. one for the limbic system. for psychologists. The second part is the pons. most interesting part of the brain is the forebrain. the pons sits in front of the medulla. conducting signals form the body up to the relevant parts of the higher brain.

moving head and shoulder Tongue muscles motor .The Peripheral Nervous System  Sensory-Somatic Nervous System  12 pairs of cranial nerves and  31 pairs of spinal nerves The Cranial Nerves Nerves I Olfactory II Optic Type sensory sensory Function Olfaction (smell) Vision (contains 38% of all the axons connecting to the brain) Eyelid and eyeball muscles Eyeball muscles Sensory: facial and mouth sensation Motor: chewing Eyeball movement Sensory: taste Motor: facial muscles and salivary glands Hearing and balance III Oculomotor IV Trochlear V Trigeminal VI Abducens VII Facial VIII Auditory IX Glossopharyngeal X Vagus XI accessory XII Hypoglossal motor motor mixed motor mixed sensory mixed mixed motor Sensory: taste Motor: swallowing Main nerve of the parasympathetic nervous system (PNS) Swallowing.

The motor or efferent fibers of the anterior root are distributed to the muscles. viscera and glands. Dorsal (12). and nonemergency situations that allows us to ―rest‖ and ―digest‖. an anterior and a posterior. Lumbar (5). so all the spinal nerves in their distribution are mixed nerves. The autonomic nervous system also acts in ―normal‖ situations to maintain normal internal functions and works with the somatic nervous system. The anterior root is composed of motor fibers. On the posterior nerve roots there are swellings.that is. Each nerve has two roots. If the anterior root of the nerves supplying a certain part be injured. or horns. thus Cervical (8). formed by projections backward and forward of the gray matter of the cord. though feeling remains. they contain both sensory and motor fibers. the posterior root of sensory fibers. which is very short as it immediately divides into the anterior and posterior primary divisions. lungs. calledganglia. .  Autonomic Nervous System The autonomic nervous systemis most important in two situations: emergency situations that causes stress and require us to ―fight‖ or take ―flight‖. They correspond in name with the bones with which they are associated. The autonomic nervous system consists of sensory neurons and motor neurons that run between the central nervous system (especially the hypothalamus and medulla oblongata) and various internal organs such as the heart. and cause their contractions. loss of power results in that part.The Spinal Nerves Thirty-one spinal nerves pass out on each side of the spinal cord through the intervertebral foramina. Each division contains fibers from both roots. Coccygeal (1). immediately beyond these ganglia the two roots unite and form a nerve trunk. which arises from two cornua. Sacral (5).

Maximally.Circle of Willis An anterial circle at the base of the brain that is of critical importance. The presence of a complete circle of Willis permits a continuing supply of blood to the entire brain and helps avert a stroke. The circle of willisreceive all the blood that is pumped up the two internal carotid arteries that come up the front of the neck and that is pumped from the basilar artery formed by the union of the two vertebral arteries that come up the back of the neck. All the principal arteries that supply cerebral hemisphere of the brain branch off the circle of Willis. This is of importance in the event that one of the major arteries (an internal carotid or vertebral artery) supplying the circle of Willis is occluded. . only a third of people enjoy a complete circle of Willis. The circle of Willis is often not complete.

depth and use of accessory muscles.ASSESSMENT Subjective: ―Nahihirapan syang huminga‖ as claimed by relative. and areas of adventitious breath sounds. To promote client expansion and drainage of secretions.  Encourage frequent position changes.   To determine oxygenation and levels of CO2 retention and to asses respiratory insufficiency.  To evaluate the degree of compromise. INTERVENTION  Place on a high fowler’s position and provide airway adjuncts and suction as indicated. Evaluate pulse oximetry & lung volumes. deep breathing  . EVALUATION  After 6 hours of nursing intervention the patient was able to demonstrate proper ventilation & adequate oxygenation.  RR=28  DIAGNOSIS Impaired gas exchange related to ventilation perfusion imbalance as evidence by dyspnea.  Note for the respiratory rate. Objective:  Weak in appearance  Dyspnea  Use of accessory muscles  Presence of crackles sound  With O2 inhalation via nasal cannula.  RATIONALE To maintain airway.  PLANNING After 6 hours of nursing intervention the patient will able to demonstrate proper ventilation & adequate oxygenation.

 Provide adequate rest and limit activities to within client tolerance. . and coughing exercises  Provide supplemental oxygen at lowest concentration indicated by client symptoms/situat ion.exercise.  To reduce anxiety. Administer IV medications as prescribed.   To treat underlying condition.  Provide psychological support.  Helps limit oxygen needs and consumption. activelisten questions and concerns.  To promote oxygenation.

.  Altered mental status. equality.ASSESSMENT Subjective: ―Tumataas ang BP nya‖ as claimed by the relative. shape.  Changes in heart rate may occur because of brain damage. size. and light reactivity.  PLANNING After 6 hours of nursing intervention the patient will demonstrate stable vital signs specifically BP.  To treat underlying condition.  Monitor neuro vital signs and evaluate pupils note. Provide adequate rest period. INTERVENTION  Monitor vital signs especially BP. To determine whether the brainstem is intact. EVALUATION  After 6 hours of nursing intervention the patient demonstrate stable vital signs specifically BP.  Administer medications as prescribed.  DIAGNOSIS Ineffective cerebral tissue perfusion related to interruption of blood flow secondary to CVA. Objective:  Lethargic  Elevated BP of 200/110mmHg  Weak and pale in appearance.    To minimize energy consumption.  Monitor heart rate and rhythm.  RATIONALE To know if the patient’s vital sign is stable.

  To avoid further injury.   Reduce the risk of skin the level of irritation or breakdown.ASSESSMENT Subjective: ―Hindi nya maigalaw ang kanyang katawan‖as claim by the relative. gently massage pressure points after each position change. Provide good skin care. EVALUATION  After 6 hours of nursing intervention the patient able to increase the level of responsiven ess. PLANNING  After 6 hours of nursing intervention the patient will be able to increase the level of responsiven ess. . Objective:  Conscious  Facial grimace noted  Right sided body weakness  Irritability  Limited ROM DIAGNOSIS  Impaired physical mobility r/t neuromuscul ar involvement as evidenced by right sided body weakness. RATIONALE  To promote good body mechanics. Provide safety measures and precautions. INTERVENTION  Assist passive and active ROM exercises.

 It helps to decrease frustration. Respect client’s preinjury capabilities & treat patient’s normally.  PLANNING After a series of nursing interventions the patient will able to establish method of communicati on in which needs can be expressed.   .  INTERVENTION Assess type or area of  dysfunction.  To reduce client’s isolation and maintain sense of connectivenes s with family.. Provides for communicatio n of needs.ASSESSMENT Subjective: Objective:     Conscious Difficulty of producing speech Inability to modulate speech Incomprehensible sounds. Encourage significant  others to persists efforts to communicate with client. EVALUATION After a series of nursing interventions the patient was able to establish method of communicatio n in which needs can be expressed   Provide alternative methods of communication  Anticipate and provide for client’s needs. It enables client to feel esteemed. RATIONALE It helps to  determine area and degree of brain involvement.  DIAGNOSIS Impaired verbal response r/t neuromuscula r impairment as evidence by difficulty producing speech.

EVALUATION  After a series of nursing interventions the patient able to perform self care activities within level of own ability. INTERVENTON  Assess abilities and level of deficit for performing ADL’s.  PLANNING After a series of nursing interventions the patient will able to perform self care activities within level of own ability.  Maintain supportive firm attitude to the client. Provide physical and psychological support for the client.ASSESSMENT Subjective: Objective:  Impaired ability to perform ADL’s  Poor hygiene  With minimal sweating  Weak and pale in appearance.  To reduce client’s isolation. .  Avoid doing things for client that client can do for self providing assistance as necessary.   To reduce anxiety.  To maintain self-esteem and promote recovery.  RATIONALE Aids in anticipating for meeting individual needs.  DIAGNOSIS Self care deficit r/t muscular impairment secondary to decreased strength and endurance as evidenced by impaired ability to perform ADL’s.

 Weak and pale in appearance.  With O2 inhalation via nasal cannula.   It helps to prevent a sudden increase in cardiac workload Encourage independence in performing activities.ASSESSMENT Subjective: Objective:  Right sided body weakness  Elevated BP of 200/110mmHg.  DIAGNOSIS Activity intolerance r/t imbalanced oxygen supply as evidenced by right sided body weakness. EVALUATION  After 6 hours of nursing intervention the patient was able to participate willingly on necessary/desir ed activities. note pulse rate and mark increase in BP after activity.  Provide assistance as needed. Encourage progressive activity/self care when tolerated.  . INTERVENTIONS  Assess the client’s response to activity.  PLANNING After 6 hours of nursing intervention the patient will be able to participate willingly on necessary/desir ed activities.  RATIONALE It helps in assessing physiologic response to the stress of activity.

DIAGNOSIS  Unilateral neglect r/t right hemiplegia from CVA of the left hemisphere as evidenced by GCS of 8. To stimulate & client’s awareness on the affected side EVALUATION  After 6 hours of nursing intervention the patient perform self care within level of ability/ acknowledg e presence of sensory perceptual impairment   Shift client’s attention towards aff4ected side   Protect affected body parts from pressure injury and burns.  GCS of 8. presence of sensory perceptual impairment.  .  To identify meaning of loss and dysfunction to the client and impact. Promote adequate rest period.  To promote comfort and relaxation. PLANNING INTERVENTIONS  After 6 hours  Observe client’s of nursing behavior & assess intervention sensory awareness the patient will perform self care  Explore and within level of encourage ability/ verbalization of acknowledge feelings.  To improve client’s interpretation of environmental stimuli.  Orient to environment as often and ensure adequate lighting and ventilation RATIONALE  To determine the extent of impairment. To promote tissue perfusion and prevent skin breakdown.ASSESSMENT Subjective: Objective:  Weak and pale in appearance  Impairment of sensory & motor function.

EVALUATION  After 6 hours of nursing intervention the patient verbalize relief of anxiety & adaptation to actual or altered body image.  INTERVENTIONS Evaluate level of client’s knowledge of anxiety r/t situation & observe emotional changes. Note signs of grieving / indicators of severe or prolonged depression.  PLANNING After 6 hours of nursing intervention the patient will verbalize relief of anxiety & adaptation to actual or altered body image.   . Provide opportunities for listening to concerns and questions. psychosocial & cognitive or perceptual changes as evidenced by actual change in structure or function. To aid in recovery.ASSESSMENT Subjective: Objective:  Conscious  Right sided body weakness  anxious  DIAGNOSIS Disturbed body image r/t biophysical.     To reduce anxiety. Encourage family members to treat client normally and not as invalid.   To decrease sense of isolation/ loneliness.  RATIONALE May indicate acceptance or nonacceptance of situation To evaluate need for counseling. Set limit on maladaptive behavior and assist to identify positive behaviors.

awareness of surroundings & cognitive function.ASSESSMENT Subjective: Objective:  Conscious  Weak in appearance  Absence of gag reflex  Dyspnea  GCS of 8.  To determine the presence of secretions/ silent aspiration. .  DIAGNOSIS Risk for aspiration r/t entry of fluids into tracheobronchi al passages as evidenced by absence of gag reflex. To determine the signs of aspiration.  . EVALUATION  After 4 hours of nursing intervention the patient was able to demonstrate techniques to avoid aspiration   To prevent aspiration and promote chest expansion. & effort. INTERVENTIONS  Assess for client’s LOC..  PLANNING After 4 hours of nursing intervention the patient will able to maintain a patent airway & clear lung sounds.  Monitor for respiratory rate. depth.  Monitor lung sounds frequently. Place client on upright position.  RATIONALE Degree of impairment may increase client’s risk of aspiration.

Transfer client with care to protect against the adverse effects of external mechanical forces such as pressure. or other signs of infection. and shear. and use lift devices. If consistent with overall client management goals. pain. friction. redness. PLANNING  After 2  hours of nursing interventi on the patient will able to  demonstr ates understa nding of plan to heal skin and prevent reinjury  INTERVENTION Monitor site of skin  impairment at least once a day for color changes. turn and position client at least every 2 hours Evaluate for use of specialty mattresses. beds  RATIONALE Systematic inspection can identify impending problems early. swelling.  Limited ROM. Avoid position client on site of skin impairment. warmth. foam wedges.ASSESSMENT Subjective: Objective:  Weak and pale in appearance. EVALUATION  After 2 hours of nursing intervention the patient demonstrates understanding of plan to heal skin and prevent reinjury   Avoid massaging around the site of skin impairment and over bony prominences. Assess client's nutritional status  To reduce shear and friction. Massage may lead to deep-tissue trauma   Inadequate nutritional intake places individuals at risk for skin injury.  Right side body weakness DIAGNOSIS  Risk for impaired skin integrity r/t physical immobiliz ation as evidenced by right sided body weakness. and pressurereducing devices in the bed. . pillows.

 Provide assistance or safety measures. RATIONALE  To have baseline of data. . PLANNING  After 2 hours of nursing intervention the patient will be able to seek help to perform tasks that are beyond her capabilities. INTERVENTION  Monitor Vital signs.  To prevent injury.ASSESSMENT Subjective: Objective:  Right hemiplegia  Weak and pale in appearance  Immobilizati on  GCS of 8 DIAGNOSIS  Risk for injury related to right hemiplegia as evidenced by right sided body weakness.   Provide adequate rest period. EVALUATION  Patient shall have seek help to perform task that are beyond her capabilities. To protect from falling out of bed.

numbness. (for increase IOP) Elevating eye pain or decreased visual acuity. Chest pain Pulmonary edema Thirst Tachycardia Hypokalemia Chronic renal failure . muscular weakness. thereby. tingling sensation of extremity and excessive thirst) (for increase ICP) Neurologic status and intracranial pressure readings. confusion. It also elevates blood plasma osmolality thus. thirst) Signs of electrolyte imbalance/deficit (e. Resectisol of the glumerular filtrate.g. dry skin. fever. promoting diuresis (treating the oliguric Classification: phase of renal failure) Osmotic and excretes toxic Diuretic materials (management for toxic overdose).g. poor skin turgor. Mannitol increases osmotic pressure (pressure needed to Brand stop the absorption of Name:Osmitr something or osmosis) ol. In the oliguric phase of acute renal failure.DRUG STUDY Drug Name Generic name: Mannitol Action Indication Oliguria renal failure Toxic overdose Edema Increased intracranial pressure (ICP) Contraindic Dosage Side Effects ation Contraindicat 100 cc Dehydration ted with IV q6 hypersensitiv hours Anuria ity to drug Headache Dehydration Blurred vision N and V Nursing Consideration Monitor for: Vital signs Intake and output Pulmonary artery pressure Signs and symptoms of dehydration (e. inhibiting the reabsorption of water and electrolytes (for relief of edema) and mobilizing fluids in the cerebral and ocular spaces (lowers intracranial or intraocular pressure). paresthesia.

Dilation of postcapillary vessels decreases venous return to the heart due to pooling of blood. to prevent situations that may cause anginal attacks Contraindication Dosage Contraindicated 25 ml IV in patients hypersensitive to nitrites. Side Effects Hypotension Chest pain Nursing Intervention Monitor vital signs Monitor client status for any occurance of any side effects. Relaxes vascular Classification: smooth muscle by stimulating production Coronary of intracellular cyclic vasodilator guanosine monophosphate. they may produce increased hypotension Headache Dizziness Fatigue Diarrhea Nausea and vomiting . sAdvise patient to avoid alcoholic beverages. head trauma. Relaxation of arterioles results in a decreased systemic vascular resistance and arterial pressure (afterload). Indication Acute anginal attacks. thus. cerebral hemorrhage or severe anemia.Drug Name Action Generic name: Isosorbide monobitrate isosorbide is the major metabolite mononitrate of isosorbidedinitrate. LV end-diastolic pressure (preload) is reduced. The mononitrate is not Brand Name: subject to first pass Monoket the metabolism.

Provides light anesthesia and anterograd e amnesia . Indication Adjunct in the manageme nt of: Anxiety Preoperativ e sedation Conscious sedation . skeletal anticonvulsants. PR. .Skeletal muscle relaxant Manageme nt of the symptoms of alcohol withdrawal Contraindication Dosage -Hypersensitivity 6 mg IV .Assess IV site frequently during administration. diazepam may cause phlebitis and venous thrombosis. N: Produces Antianxiety agents. sedative/hyptonics. Observe depressed patients closely for suicidal tendencies. . . inject deeply into deltoid muscle for maximum absorption. . .Prolonged high-dose therapy may lead to psychological or physical dependence. . decreased tremulousness.Treatment of status epilepticus/ uncontrolle d seizures . If IM route is used.Cross-sensitivity with other benzodiazepines may occurs Comatose patients Pre-existing CNS depression Uncontrolled severe painUse cautiously in: 1) Hepatic dysfunction 2) Severe renal impairment 3) History of suicide attempt or drug dependence Side Effects CNS: dizziness drowsiness lethargy hangover headache depression EENT: blurred vision RESP: respiratory depression CV: hypotension GI: constipation diarrhea nausea vomiting DERM: rashes psychologica l dependence Nursing Intervention Monitor BP.Drug Name Action GENERIC NAME: Reduces Diazepam anxiety by increasing or BRAND NAME: facilitating the inhibitory Valium neuritransmitt er activity of CLASSIFICATIO GABA. control of seizures.IM injections are painful and erratically absorbed. muscle skeletal muscle relaxation by relaxants (centrally inhibiting spinal acting) polysynaptic afferent pathways. Restrict amount of drug available to patient.RR prior to periodically throughout therapy and frequently during IVs therapy.Caution patient to avoid taking alcohol or other CNS depressants concurrently with this medication.Effectiveness of therapy can be demonstrated by decrease anxiety level.

ranscription. Instruct patient to take ciprofloxacin with a full glass of water (8 ounces).Drug Name Generic Name: Ciprofloxacin Brand name: Quinosyn Classification: antibacterial Action Interferes with DNA grynase and topoisomerase IV. coli. Campylobacter jejuni . and joints caused by susceptible bac teria. but do not use them alone when taking ciprofloxacin. Ciprofloxacin is also frequently used to treat urinaryinfectio nscaused by bacteria such asE. Ciprofloxacin is effective in treating infectious diarrheas cause d by E. Topoimeserase iv plays an important role in the partitioning of chromosomal DNA during bacterial cell division. coli. and repair of bacterial DNA. Tell patient to be careful if he plans to drive or do anything that requires him to be awake and alert. . and Shigellabacteri a Side Effects Nausea Vomiting Stomach pain Heartburn DiarrheaFeeling an urgent need to urinate Headache Hives Difficulty breathing or swallowing Hoarsenessor throat tightness Nursing Intervention Instruct patient not to take ciprofloxacin with dairy products such as milk or yogurt. or with calciumfortified juice. They could make the medication less effective. lungs. IV q12 infections of the skin. airways. bones. Indication Contraindication Dosage Ciprofloxacin Hypersensitivity 200 mg is used to treat to drug. He may eat or drink dairy products or calcium-fortified juice with a regular meal. DNA grynase is an enzyme needed for replication.

Nursing Intervention name: Antipyretic: Reduces fever by acting directly on the hypothalamic heat-regulating center to cause vasodilation and sweating.Drug Name Generic paracetamol Brand Name: acetaminophen Classification: Analgesic antipyretic Action Indication Contraindication Dosage Side Effects Skin rashes and other allergic reactions occur occasionally. especially in usually individuals with erythematous or poor nutrition. . urticarial but sometimes more Give drug with serious and may food if be accompanied GI upset occurs by dug fever and mucosal lesion. which helps dissipate heat. Discontinue drug if hypersensitivity reactions occur. to 300 mg IV q4 or Monitor for signs of symptoms of ypertoxocity even with moderate acetaminophen The rash is doses. moderate intensity. Analgesic: Site and mechanism of action unclear Paracetamol Hypersensitivity relieves pain acetaminophen and fever paracetamol.

stimulates brain function. Citicholine is Citicholine is 1 gram IV q8 indicated in CVD contraindicated with: in acute recovery phase in severe  Any allergy or s/sx of hypersensitivity cerebrovascular to the drug insufficiency and  Unconsciousnes in-cranial s traumatism and  Brain surgery their sequellae. chest tightness. It is also Zynapse. the Cholinerve biosynthesis of lecithin. Neurotropics. tingling Hold drugs if in mouth and allergic reactions throat occur. Citicholine in CVA. .Drug Name Generic Name:citicholin e sodium Action Indication Contraindication Dosage It increases blood flow and O2 consumption Brand Name: in the brain. Monitor signs vital Side Effects Assess neurologic status. Monitor allergic swelling in face or reactions hands. involved in Somazine. Peripheral Vasodilators. Nursing Intervention Itching or hives. Cerebral Activators. Classification: CNS Stimulant.

and vascular supply to skeletal muscles) than on beta1 (heart) receptors. DuoNeb selective beta2adrenergic agonist with Classifications:autonomic comparatively nervous system agent. Contraindication Generic name:albuterol Synthetic and ipratropium sympathomimetic amine and Brand name: moderately Combivent. Inhibits histamine release by mast cells. nausea. or other reversible obstructive airway diseases. Monitor vital high blood combivent nervousness. bronchitis. sleeping. Nursing interventions Heart disease. uterus. trouble epilepsy.dizziness. signs pressure. long action. or of side effects medication runny nose should be used Do not allow only when clearly the patient to needed during drive pregnancy. 1 dose of Headache. Discuss the risk and benefits with your doctor. drug dry mouth/throat. any occurrence allergies. This drug may be excreted into breast milk Dosage Side effects . Minimal or no effect on alphaadrenergic receptors. Monitor for diabetes.Drug name Action Indication To relieve bronchospasm associated with acute or chronic asthma. This coughing. Acts more prominently bronchodilator on beta2 receptors (particularly (respiratory smooth smooth muscles muscle relaxant) of bronchi. Also used to prevent exerciseinduced bronchospasm.

ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION Subjective: • Objective: • • Conscious Right sided body weakness anxious • Disturbed body image r/t biophysical. After 6 hours of nursing intervention the patient verbalize relief of anxiety & adaptation to actual or altered body image. Note signs of grieving / indicators of severe or prolonged depression. comfort and relaxation. • May indicate acceptance or nonacceptance of situation • • • To evaluate need for counseling.period. • Provide opportunities for listening to concerns • To reduce . • Evaluate level of client’s knowledge of anxiety r/t situation & observe emotional changes. psychosocial & cognitive or perceptual changes as evidenced by actual change in structure or function. • After 6 hours of nursing intervention the patient will verbalize relief of anxiety & adaptation to actual or altered body image.

awareness of surroundings & cognitive function. To decrease sense of isolation/ loneliness. • • Set limit on maladaptive behavior and assist to identify positive behaviors. anxiety. ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION Subjective: • Objective: • • • Conscious Weak in appearance Absence of gag reflex Risk for aspiration r/t entry of fluids into tracheobronchi al passages as evidenced by absence of gag reflex. • To aid in recovery.and questions. • • After 4 hours of nursing intervention the patient was able to demonstrate techniques to avoid aspiration • To prevent . • After 4 hours of nursing intervention the patient will able to maintain a patent airway & clear lung sounds. • Encourage family members to treat client normally and not as invalid. • Degree of impairment may increase client’s risk of aspiration. • Assess for client’s LOC.. Place client on upright position.

• To determine the presence of secretions/ silent aspiration. aspiration and promote chest expansion. • To determine the signs of aspiration.• • Dyspnea GCS of 8. depth. • Monitor for respiratory rate. . • Monitor lung sounds frequently. ASSESSMENT Subjective: DIAGNOSIS • Risk for impaired PLANNING • INTERVENTION • Monitor site of skin • impairment at least RATIONALE Systematic inspection can identify impending • EVALUATION After 2 hours of nursing After 2 hours of . & effort.

Objective: • Weak and pale in appearance. Limited ROM. redness. foam wedges. nursing interventi on the patient will able to demonstr • ates understa nding of plan to heal skin and prevent reinjury • once a day for color changes. pillows. Massage may lead to deep-tissue trauma • Avoid massaging around the site of skin impairment and over bony prominences. Right side body weakness • • skin integrity r/t physical immobiliz ation as evidenced by right sided body weakness. warmth. pain. or other signs of infection. and pressurereducing devices in the bed. problems early. swelling. friction. and shear. and use lift devices. turn and position client at least every 2 hours intervention the patient demonstrates understanding of plan to heal skin and prevent reinjury • Transfer client with care to protect against the adverse effects of external mechanical forces such as pressure. Assess client's nutritional status • • . If consistent with overall client management goals. beds • To reduce shear and friction. Evaluate for use of specialty mattresses. Avoid position client on site of skin impairment.

• Monitor Vital signs. • • • • Provide adequate rest period. To protect from falling out of bed.• Inadequate nutritional intake places individuals at risk for skin injury. . INTERVENTION Subjective: • Objective: • • Right hemiplegia Weak and pale in appearance Immobilizati on GCS of 8 Risk for injury related to right hemiplegia as evidenced by right sided body weakness. • • Provide assistance or safety measures. To prevent injury. Patient shall have seek help to perform task that are beyond her capabilities. RATIONALE • To have baseline of data. EVALUATION • ASSESSMENT DIAGNOSIS PLANNING • After 2 hours of nursing intervention the patient will be able to seek help to perform tasks that are beyond her capabilities.

osmosis) of the Contraindi 100 cc Dehydration IV q6 catted renal hours with failure Anuria hypersensi tivity to drug Toxic Headache overdose Edema Dehydrati on Pulmonary artery pressure Signs and symptoms of . Mannitol increases osmotic pressure (pressure needed to stop the Brand absorption of Name:Osmi something or trol.DRUG STUDY Drug Name Generic name: Mannitol Action Indicatio n Oliguria Contrain dication Dosag e Side Effects Nursing Consideration Monitor for: Vital signs Intake and output In the oliguric phase of acute renal failure.

poor skin turgor. It also elevates blood plasma osmolality thus. fever. promoting diuresis (treating the oliguric phase of renal failure) and excretes toxic materials (management for toxic overdose).g. inhibiting the reabsorption of water and electrolytes (for relief of edema) and mobilizing fluids in the cerebral and ocular spaces (lowers intracranial or intraocular pressure). Blurred vision Increased intracrani al pressure (ICP) dehydration (e. numbness. dry skin. thirst) N and V Signs of electrolyte imbalance/deficit (e. Chronic failure renal . status and pressure Hypokalemia (for increase IOP) Elevating eye pain or decreased visual acuity.Resectisol Classificati on:Osmotic Diuretic glumerular filtrate. tingling sensation of extremity and excessive thirst) (for increase ICP) Chest pain Pulmonary edema Thirst Tachycardia Neurologic intracranial readings.g. confusion. muscular weakness. paresthesia. thereby.

Indicati on Acute anginal attacks. they may produce increased hypotension Fatigue Diarrhea Nausea and vomiti ng . The mononitrate is not subject to first pass the metabolism. Relaxes vascular smooth muscle by stimulating production of intracellular cyclic guanosine monophosphate. cerebral hemorrhage or severe anemia. Dilation of postcapillary vessels decreases venous return to the heart due to pooling of blood. LV enddiastolic pressure (preload) is reduced. Headache Classificatio n: Coronary vasodilator Dizziness sAdvise patient to avoid alcoholic beverages. thus. head trauma. Chest pain Monitor client status for any occurance of any side effects.Drug Name Generic name: isosorbide mononitrate Action Isosorbide monobitrate is the major metabolite of isosorbidedinitrate . to prevent situation s that may cause anginal attacks Contraindica tion Dosage Side Effects Hypotension Nursing Intervention Monitor vital signs Brand Name: Monoket Contraindicat 25 ml IV ed in patients hypersensitive to nitrites.

RR prior to periodically throughout therapy and frequently during IVs therapy. GABA.Pre-existing CNS mg CNS: dizziness drowsines s lethargy hangover headache depressio n EENT: blurred vision Monitor BP. sedation sedative/hypto .Relaxation of arterioles results in a decreased systemic vascular resistance and arterial pressure (afterload). . PR. mitter Consciou anticonvulsants activity of s .Assess IV site frequently during administration. Drug Name Action Indicati on Contraindica tion Dosag e Side Effects Nursing Intervention GENERIC NAME: Reduces Adjunct anxiety by in Diazepam the increasing manage BRAND NAME: or ment of: Valium facilitating Anxiety CLASSIFICATIO the Preopera N: inhibitory tive Antianxiety neuritrans sedation agents. Prolonged high-dose therapy may lead to psychological or physical . diazepam may cause phlebitis and venous thrombosis.Produces - 6 Hypersensitivit IV y Crosssensitivity with other benzodiazepin es may occurs Comatose patients .

Skeletal muscle relaxant Manage ment of the symptom s of alcohol withdraw al depression . If IM route is used. Provides light anesthes ia and anterogr ade amnesia Treatme nt of status epileptic us/ uncontro lled seizures . skeletal muscle relaxants (centrally acting) skeletal muscle relaxation by inhibiting spinal polysynapt ic afferent pathways. .Effectiveness of therapy can be demonstrated by decrease anxiety level. .nics. Restrict amount of drug available to patient.IM injections are painful and erratically absorbed. inject deeply into deltoid muscle for maximum absorption.Caution patient to avoid taking alcohol or other CNS depressants concurrently with this medication. control of seizures.Uncontrolled severe painUse cautiously in: 1) Hepatic dysfunction 2) Severe renal impairment 3) History of suicide attempt or drug dependence RESP: respirator y depressio n CV: hypotensi on GI: constipati on diarrhea nausea vomiting DERM: rashes psychologi cal dependence dependence. . Observe depressed patients closely for suicidal tendencies. decreased tremulousness. .

Drug Name Action Indication Contraindica tion Dosa ge Side Effects Nursing Intervention .

Quinosyn and repair of bacterial DNA. DNA grynase is an enzyme Brand needed for name: replication. Ciprofloxaci n is effective in treating infectious diarrheas c aused by E. ranscription. Ciprofloxaci n is also frequently used to treat urinaryinfec tionscaused by bacteria such asE. Instruct patient to take ciprofloxacin with a full glass of . airways.Generic Name: Interferes with DNA grynase and Ciprofloxaci topoisomera n se IV. Classificatio Topoimesera n: se iv plays antibacteria an important l role in the partitioning of chromosoma l DNA during bacterial cell division. bones. and joints caused by susceptible bacteria. treat infections of the skin. 200 Nausea mg IV Vomiting q12 Stomach pain Heartburn DiarrheaFeelin g an urgent need to urinate Headache Hives Difficulty breathing or swallowing Hoarsenessor throat tightness Instruct patient not to take ciprofloxacin with dairy products such as milk or yogurt. lungs. Tell patient to be careful if he plans to drive or do anything that requires him to be awake and alert. but do not use them alone when taking ciprofloxacin. or with calcium-fortified juice. He may eat or drink dairy products or calcium-fortified juice with a regular meal. They could make the medication less effective. coli. Ciprofloxac Hypersensitivi in is used to ty to drug.

Campyloba cter jejuni . Drug Name Action Indication Contraindicatio n Dosage Side Effects Nursing Intervention .coli. and Shigellabact eria water (8 ounces).

in The rash is especially individuals with usually erythematous poor nutrition. which helps dissipate heat. Hypersensitivity to acetaminophen or paracetamol. Analgesic: Site and mechanism of action unclear Paracetamol relieves pain and fever moderate intensity. 300 mg IV Skin rashes q4 and other allergic reactions occur occasionally. drug if hypersensitivit y reactions occur.Generic name: Antipyretic: paracetamol Reduces fever by acting Brand Name: directly on the acetaminophen hypothalamic heatregulating Classification: center to Analgesic cause antipyretic vasodilation and sweating. . Monitor for signs of symptoms of ypertoxocity even with moderate acetaminophen doses. or urticarial but sometimes Give drug with more serious food if and may be GI upset occurs accompanied by dug fever and mucosal Discontinue lesion.

Drug Name Action Indication Contraindication Dosage Side Effects Nursing Intervention .

Neurotropics . Cerebral Activators. Peripheral Vasodilators. stimulates brain function. Stimulant. . brain. Itching or hives. on in the Somazine. swelling in face or hands.Generic Name:citicho line sodium It increases blood flow and O2 Brand consumpti Name: Zynapse. Citicholine is Citicholine is 1 gram IV q8 indicated in contraindicated CVD in acute with: recovery • Any allergy phase in or severe s/sx of cerebrovascul hypersensiti ar vity to the insufficiency drug and in-cranial • Unconscious traumatism and their ness sequellae. tingling in mouth and throat Monitor allergic reactions Hold drugs if allergic reactions occur. It is Cholinerve also involved in the biosynthes Classification is of : CNS lecithin. Monitor signs vital Assess neurologic status. chest tightness. • Brain Citicholine in surgery CVA.

epilepsy. This drug may be excreted into breast milk Headache. trouble sleeping. Also used to prevent exerciseinduced bronchospas m. uterus. diabetes. Acts more Classifications:auton prominently omic nervous on system agent. beta2 receptor s (particularly smooth bronchodilator muscles of bronchi. 1 dose of high blood combivent pressure. Heart disease. or runny nose Monitor for any occurrence of side effects Do not allow the patient to drive . and (respiratory smooth vascular supply to muscle relaxant) skeletal muscles) than on To relieve bronchospas m associated with acute or chronic asthma. coughing.dizzin ess. or other reversible obstructive airway diseases. bronchitis.Drug name Action Indication Contraindica tion Dosage Side effects Nursing interventio ns Monitor vital signs Generic Synthetic name:albuterol and sympathomi ipratropium metic amine and moderately selective Brand name: beta2Combivent. dry mouth/throat. drug allergies. DuoNeb adrenergic agonist with comparatively long action. Discuss the risk and benefits with your doctor. nervousness. This medication should be used only when clearly needed during pregnancy. nausea.

Minimal or no effect on alphaadrenergic receptors.beta1 (heart) receptors. Inhibits histamine release by mast cells. .

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