UNIVERSITY OF SANTO TOMAS

COLLEGE OF NURSING
A.Y. 2023-2024 Second Semester

Partial fulfillment of the requirements in

NUR81029 - Intensive Nursing Practicum
Related Learning Experience

NURSING CASE ANALYSIS:

Acute Intracerebral Hemorrhage

4NUR-1, RLE 4
BARAYOGA, Denise Ysabel O.
BARTOLOME, Carla Mae S.

Submitted to:
Asst. Prof. Alma Lacuata Caleon, MAN, RN
Asst. Prof. Maria Victoria V. Bongar, MPhED, RN

Submitted on:
April 27, 2024
 University of Santo Tomas
College of Nursing

HEALTH HISTORY

I. Biographical Data:

Name:__________________________________________________________________
Address:________________________________________________________________
Age: Sex: Citizenship: Religion:
Birthdate: Civil Status: Educ. Attainment:
BirthPlace:
Race: _________________________________________________________________
Occupation:_____________________________________________________________
Health Insurance: Philhealth? ___Yes ___No
Health Maintenance Organization (HMO)? ___Yes ____No
If Yes, please indicate: _________________________
Information obtained from: (Please check appropriate box.)
□ Patient
□ Others: Name ________________________________
Relationship: __________________________
Reliability of Source:______________________________________
Date Information Obtained:_________________________________

II. History of Present Health Illness:

Chief Complaint: ___________________Diagnosis: ________________________________

_____________________________________________________________________________________

____________________________________________________________________________________

III. Past Health History (from childhood to present)

Surgeries: (Type, Dates, Hospital)

Hospitalizations & Illnesses( Kind, Inclusive Dates, Hospital)

_____________________________________________________________________________
_____________________________________________________________________________

____________________________________________________________________________
Allergies: Food?___Yes____No; If Yes, kind of food?___________Reactions?_______________
Allergies: Medicine?____Yes____No; If Yes, name of medicine?___________
Reactions?_____________
Allergies : Latex?___Yes____No. Reactions _________________________________________
Allergies: Environment?____Yes_____No; If Yes, what kind?_________Reactions?__________
Immunizations : Complete?___Yes____No
Flu vaccine: Received? ___Yes____No; If Yes,Date received__________
Pneumonia vaccine: Received? ___Yes____No; If Yes,Date received__________

Medication Reconciliation:
Medicines taken at Home Medicines taken in the Hospital (if applicable)

IV. Family Health History

V. Psychosocial History:
A. Past events related to health:
Place of birth:______________
Places lived:__________________________________________________________________
Significant childhood/adolescent experiences:
_____________________________________________________________________________
_____________________________________________________________________________
B. Education and Occupation:
Jobs held in the past:
_____________________________________________________________________________
_________________________________________________________________________
Current position or job:__________________________________________________________
Length of time at position:_________________________
Work satisfaction and career goals:
_____________________________________________________________________________
_____________________________________________________________________________
________________________________________________________________________
C. Lifestyle Patterns:
Exercise:Type___________Frequency_____________Time spent_____________________
Sleep : Time person retires________Hrs per night_________Comfort Measures___________
Awakens rested?____Yes____No
Recreation:Type of activity____________Time spent________________
Nutrition:
(24hr diet recall):
Breakfast:__________________________________________________
Lunch:_____________________________________________________
Supper:____________________________________________________
Snacks:____________________________________________________
Restrictions:______________________________________________________
Idiosyncrasies:____________________________________________________
Caffeine :_____coffee____tea____chocolate_____soda/cola
Amount_______Frequency__________
Tobacco use: ____Yes___No. If Yes, how long?_______How much?___packs /day___sticks/day
Kind?(cigarette,pipe, cigar, marijuana)_________________________
Desire to quit?_____________________

Alcohol Use: ____Yes____No. If Yes, how long?_____How much?_____per day______per week

Kind?__________________________

Illicit Drug use: ___Yes___No. If Yes, how long?_____How much?____per day______per week

Kind?__________________________Route of administration?________________

Sexually active:____Yes ___No. Any sexually transmitted disease? __Yes__No. If Yes, indicate
what kind________________________________________________________

E: Self Concept:
View of self in the present:___________________________________________________
View of self in future:_______________________________________________________
Body image (level of satisfaction, concerns):
_____________________________________________________________________________
_____________________________________________________________________________

F. Physical or Mental disability:

Presence of disability (physical / mental):_____________________________________________
Effects of disability on function / ADLs:_______________________________________________
Accommodations needed to support
Complete assistance from relatives
functioning:________________________________________

G.Risk for abuse:

Physical injury in the past:________________________________________________________
Afraid of partner, caregiver or family member:_________________________________________

H. Stress and Coping Mechanisms:

Major concerns or problems at present:______________________________________________
Daily “Hassles”:_________________________________________________________________
Past coping patterns and outcomes:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Present coping strategies and anticipated outcomes:
_____________________________________________________________________________
_____________________________________________________________________________
Individual ‘s expectations of family/friends and health care team in problem resolution:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

I. Environment:
Physical :Living arrangements
Type of Housing:___________________________
Presence of Hazards:_______________________
Spiritual :
Religious beliefs & practices pertaining to health & illness:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Interpersonal :
Ethnic background:
Language/s spoken:_____________________________________
Folk practices used to maintain health or to cure
illness:_____________________________________________________________
__________________________________________________________________
__________________________________________________________________
Family relationships:
Family structure:_________________________________________________
Roles :_________________________________________________________
Communication patterns:__________________________________________
Support system:_________________________________________________
Friendships: (quality of relationships)
__________________________________________________________________
__________________________________________________________________

VI. ADL Functional Assessment

Areas Scores
1. Grooming
2. Dressing UE (upper extremity)
3. Dressing LE (lower extremity)
4. Toileting/elimination
5. Feeding/eating
6. Bathing
7. Vision
8. Cognition
9. Memory
10. Communication

SCORES:

0 =activity did not happen

7 = independent; no help nor assistive needed to complete the task

6 = modified independence; need an assistive device to complete task on her/ his own
5 =supervision; requires 1 person to supervise only with no touching of the patient

4 =minimal assistance; requires 25% assistance from staff/ others to complete task
3 =moderate assistance; requires 50% assistance from staff/ others to complete task

2 = maximal assistance; requires 75% assistance from staff/ others to complete task

1 =dependent ; requires 100% assistance from staff / others to complete task

 UNIVERSITY OF SANTO TOMAS
COLLEGE OF NURSING
España Boulevard, Sampaloc, Manila, Philippines 1015
Tel. No. 406-1611 loc.8241 | Telefax: 731-5738 | Website: www.ust.edu.ph

Student’s Review of System Assessment Guide

Directions: Please fill out the form by answering or placing checkmark (√) on the item that corresponds to your answer to the
given statement. Please use the comment section for additional information not found in the checklist. If unable to assess,
indicate reason in the comment section.

Patient’s Name (Initials): _______________________ Date: ___________ Unit/Ward: __________ Age: ___________
Chief Complaint: ___________________________ Diagnosis: ____________________Gender: ___Female ___Male
Vital signs: Respiratory:
BP: ________ ( ) Lying ( ) Sitting ( ) Standing ( ) RUE* ( ) LUE* ( ) LLE* ( ) RLE* Within Normal Limits / No problems noted
Rested? ( ) Yes ( ) No Rhythm / effort: ( ) irregular ( ) shallow ( ) deep ( ) retractions
PR:________ ( ) Apical ( )RUE* ( ) LUE* ( ) LLE* ( ) RLE* Chest shape: ( ) barrel ( ) pigeon ( )funnel / sunken
RR:_______ Temp : _______ ( ) Oral ( ) Axillary ( ) Tympanic Expansion: ( ) asymmetrical
Pain: Rate? At rest ________ With activity_____________ Lung sounds: ( )crackles: ( ) fine ( ) coarse LOCATION __________
( ) Numeric scale ( ) Other scale; specify________ Pain Onset? ____________ ( ) wheeze: ( ) inhalation ( ) exhalation LOCATION_________
Quality? ______________ Location? _______________________ ( ) rhonchi : LOCATION _______________
Radiates? ( ) Yes; where? _________ ( )No ( ) diminished: LOCATION_________ ( ) absent: LOCATION___________
What aggravates? ___________________________________________ Cough: ( ) Yes ( ) No ( ) Non productive/ Dry ( ) Productive
What relieves? ______________________________________________ Sputum: Color ________ Amt ________ Consistency______________
On pain medications? ( ) Yes ( ) No; Specify ___________________________ Able to expectorate sputum?: ( ) Yes ( ) No
Comments: Suctioning? ( ) oral ( ) trach ( ) ET ( ) nasopharyhngeal
Specify usual time of occurrence of coughing:____________________
Nasal Discharge? ( ) Yes ( ) No; Color __________ Amt__________
( ) Thick consistency ( ) Thin consistency
( ) O2 inhalation: ( ) NC ( ) mask ( ) others; specify_________________________
Regulation ______L/min; O2 Humidifier in use? ( ) Yes ( ) No
Comments:

Positioning:
( ) sitting ( ) supine ( ) prone ( ) side-lying; location_____ ; HOB: degree______
Comments : Cardiovascular:
Within Normal Limits / No problems noted
Heart: rhythm / quality: ( ) irregular ( ) regularly irregular ( ) irregularly irregular
( ) weak / thready ( ) bounding
( ) Murmurs: LOCATION___________
Psychosocial: Neck/ jugular vein distention? ( ) Yes ( ) No
Mood: ( ) Pleasant ( ) Sad ( ) Flat/ Indifferent Peripheral Pulses: ( ) absent ( )unequal ( ) weak: LOCATION__________
( ) Anxious ( ) Calm ( ) Cooperates with Care Capillary Refill: ( ) fingernail ( )toenail ( ) delayed :more than 3secs (site):____________
( ) Fearful thoughts ( ) Irritability Peripheral Vascular (legs): ( ) pallor ( )increased warmth ( )ulcers ( ) redness
Comments : ( ) increased coolness ( )RLE* ( )LLE*
Edema: ( ) non-pitting: location_____ ( ) pitting: ( ) 1+ ( )2+ ( ) 3+ ( )4+ ; Location_____
( ) Peripheral IV line: ( ) Central IV line Location__________ Type __________
Gauge #_______Date inserted__________ Date IV tubing last changed____________
Presence of s/s of: ( ) infiltration ( ) inflammation ( ) infection
Comments :

Neurology:
Within Normal Limits / No problems noted
LOC: ( )Alert ( ) Lethargic ( ) Comatose GCS Total=____ ( E=____, V=_____, M=_____)
Orientation: ( ) Person ( ) Place ( ) Time ( ) Reasoning Gastrointestinal:
Pupils: ( ) reactive ( ) non-reactive ( ) brisk ( ) sluggish ( ) R* ( ) L* ( ) Bilateral Within Normal Limits / No problems noted
Pupillary size: ( )pinpoint ( ) dilated size:______ mm ( ) R* ( )L* ( )Bilateral Abdomen contour: ( ) round ( ) flat ( )protuberant / overly distended ( )scaphoid/ sunken
Aphasia: ( ) receptive ( ) expressive ( ) both / global Bowel sounds X 4 quadrants: ( ) hypoactive ( ) hyperactive ( )absent LOCATION______
Coherence of thought process? ( ) Yes ( ) No ( ) ABD tenderness: LOCATION_______ ( ) ABD rigidity: LOCATION_________
Extremity weakness: ( ) RUE* ( )LUE* ( )LLE* ( )RLE* Bowel Movement: date of last BM: ______ usual pattern: ______________
Extremity paralysis: ( ) RUE* ( ) LUE* ( )LLE* ( )RLE* Stool : consistency______________ color__________ amt________________
Tremors : ( )RUE* ( )LUE* ( )LLE* ( )RLE* ( ) nausea; frequency _________; timing___________
Vertigo : ( ) Yes ( ) No Numbness?: Location___________ ( ) vomiting; frequency _________ amt_________ color _______ timing_________
Comments: Presence of ABD. Mass? ( ) Yes ( ) No Location: ______________
Comments :

GU & GYN:
Eyes and Ears: Within Normal Limits / No problems noted
Within Normal Limits / No problems noted Bladder: ( ) distended ( ) tender
( ) Scleral discoloration; color______ location_____ Kidney : ( ) positive flank pain ( ) L * ( ) R*
( ) Eye drainage; color______ amt__________ odor_______ location_____ Urine: color_____ ( )cloudy ( )blood ( ) burning ( ) diminished stream ( )incontinent
( ) Blurring of vision; location____ ( ) Eyeglasses ( ) Contact lens ( ) foley catheter ( ) condom catheter ( ) peritoneal dialysis ( ) hemodialysis
( ) Nystagmus; location___ ( ) Strabismus: ( )convergent ( ) divergent ; location_____ ( ) Presence of cystostomy tube Location ( ) R* ( ) L*
( ) Hearing difficulty; Location____ ( ) hearing aids; Location_____ Discharge from genitalia? ( )Yes ( )No Color:_______ Amt: __________
( ) Ear drainage; color_______ amt_________ odor ________location_____ For Female Patients only:
Comments: Last Menstrual Period (LMP) (date):_____________ ( ) menopausal ( ) pregnancy
Comments:

UST: A012-00-FO65
 Musculoskeletal:
Within Normal Limits / No problems noted
Muscle tone: ( ) flaccid/paralyzed ( ) atrophy LOCATION_______________
Strength: ( ) UE* ( )LE* ( ) weak ( ) paralysis LOCATION____________
Range of Motion (ROM): ( )limited LOCATION____________
Gait: ( ) unsteady ( )other: specify__________
( ) Assistive device: specify____________
Activity assistance level: ( ) Dependent 100% ( ) Maximal 75% ( ) Moderate 50%
( ) Minimal 25% ( ) Supervision / Stand-by assist; no touching of patient
( ) Modified Independence; uses assistive devices independently plus no touching of
patient by others
( ) Independent; no assistive device in use plus no assistance from others
Comments :

Integumentary:
Within Normal Limits / No problems noted
Skin Color: ( ) pale ( ) jaundice ( ) cyanotic
Temp / texture / moisture: ( ) cool ( )rough ( ) moist ( ) dry
( )sweating ( )oily
Presence of Rash?: ( )Yes ( ) No location _______
size(cm): length_____ depth____ width________
wound bed color_________ characteristics__________
( ) moist ( ) dry
Presence of Wound?: ( ) Yes ( ) No location ____________
size(cm):length _______depth ______width_______
drainage_________; wound bed color__________ ; odor________
dressing, if any____________________
Presence of Pressure sore: ( ) Yes ( ) No location__________ ;
stage: ( ) 1 ( ) 2 ( )3 ( ) 4 ; Eschar?: ( ) Yes ( )No
size (cm): length _________depth _______width___________
drainage_______; wound bed color:__________ ; odor______________
dressing, if any_______________________________
Presence of Incision site: ( ) Yes ( ) No location__________
size (cm): length _________depth _______width___________
drainage_________; wound bed color__________ ; odor________
presence of ( ) staples ( ) sutures ( ) dermabond
dressing, if any____________________
Comments:

Please use drawing below for additional information:

PRINTED NAME/ SIGNATURE:

DATE & TIME:

*RUE – Right Upper Extremity *LUE- Left Upper Extremity

*R- Right *L- Left
*LLE- Left Lower Extremity *RLE- Right Lower Extremity
*UE- Upper Extremity *LE- Lower Extremity

UST: A012-00-FO65
 COURSE IN THE WARD

Day 1 Day 2 Day 3 Day 4

(April 10) (April 11) (April 12) (April 13)

Problem 1: Risk for Impaired Skin

Integrity related to
prolonged bed rest and
reduced physical
mobility secondary to
Acute Cerebral
Hemorrhage

S/O Data: Subjective:

Caregiver verbalized,
“Medyo namumula na
po yung sa may pwetan
niya kasi po nabasa ng
ihi at dumi niya.”

Objective:
● With right
hemiparesis
● Completely
assisted with
ADLs
● With diaper
● Cannot turn to
sides
independently
● Dry skin
● On bedsore
precaution
● With turning
schedule every 2
hours

BP: 140/80
TEMP: 36.5
RR: 18
NC @2LPM

Awake, alert, oriented,

(+) expressive aphasia,
(+) dysarthria, follows
commands, pupils
2-3mm, right facial
central palsy

Manageme 8:45AM (Neuro)

nt: Facilitate egg crate
mattress
Bedsore precaution at
all times
Do 3 oz water test ℅
NPROD
Start bladder training
for 6 cycles

8:20PM (Neuro)
Encourage relatives to
do gradual to full back
rest
Elevation, passive
 ROM and ankle
pumping exercises as
tolerated under strict
BP precautions
Strict bed turning Q2
hours to avoid
bedsores

Nursing
Management:
Encouraged relatives
to help patient turn to
sides every 2 hours,
kept linens clean and
dry, assisted in
changing of diaper,
monitored for further
redness and skin
irritation, assisted to a
comfortable position,
elevated heels off bed
with pillows,
maintained HOB at 30
degrees or more

Rationale: The management plan

for this patient with
acute cerebral
hemorrhage focuses
on preventing
complications of
prolonged bed rest and
reduced mobility.
Strategies include
implementing bedsore
precautions with
regular turning every 2
hours, using
pressure-relieving
surfaces, initiating
bladder training to
maintain skin dryness,
and encouraging
gradual backrest with
passive range of
motion exercises to
prevent contractures
and venous stasis.
Neurological
monitoring is essential
to detect any
worsening conditions,
while involving family
members in caregiving
and education ensures
continuity of care.
Maintaining
respiratory support
with the head of bed
elevated at 30 degrees
or more helps prevent
 aspiration. Thus, this
comprehensive
approach aims to
preserve skin integrity,
optimize neurological
outcomes, and involve
caregivers in the
patient's recovery
process.

Response: Patient able to tolerate

turning, skin is clean
and dry

Problem 2: Impaired Gas Impaired Gas Exchange

Exchange related to related to lung
lung infiltrates infiltrates secondary to
secondary to CAP-MR CAP-MR

S/O Data: Objective: Objective:

● O2 is 93-94% ● RR: 17-19
● RR is 21 ● O2: 94-97%
● X-ray shows ● No dyspnea
lung infiltrates in
● No desaturations
bilateral lower
lobes
● (+) bibasal
● With labored crackles
breathing ● No cough
● Decreased
breath sounds
● Bilateral
crackles and
rales upon
auscultation

BP: 140/80
TEMP: 36.7
HR: 63
RR: 21
(+) Right facial
asymmetry
No febrile episode

Awake, alert, oriented,

(+) expressive aphasia,
(+) dysarthria, follows
commands, pupils
2-3mm

Manageme 3:45PM (Pulmo) 9:30 AM (PULMO)

nt: Await blood and ● Strict aspiration
sputum CS precaution
Continue the following ● Deep breathing
antibiotics: exercises
● Ampicillin-Sul
bactam 1.5g/IV 10:30 AM (PULMO)
Q6h ● Continue
● Azithromycin ampicillin-sulba
200mg/5ml ctam 1.5 g/IV
12.5ml Q24h q6

Nursing 11:26 AM (PULMO)

Management: ● Discontinue
 Encouraged deep Azithromycin
breathing exercises, Nursing Management:
elevated HOB, advised Frequent monitoring of
coughing and turning vital signs and oxygen
techniques every 2 saturation; Elevate head
hours, administered of bed; Oral hygiene
Ampicillin-Sulbactam maintenance; Advise
and Paracetamol as adequate rest periods
ordered and limit activities;
Encourage frequent
deep breathing and
coughing exercises;
Provide a calm and
quiet environment to
allow client to relax

Rationale: The management for Patients with impaired

impaired gas exchange gas exchange in stroke
in this patient with patients with
community-acquired pneumonia require a
pneumonia (CAP) multifaceted approach
with Moderate Risk to optimize respiratory
involves addressing function and promote
the underlying lung recovery. Strict
infiltrates. This aspiration precaution
includes administering measures are essential
appropriate antibiotics to prevent further
to target the infection, aspiration of oral or
such as gastric contents, which
Ampicillin-Sulbactam can exacerbate lung
and Azithromycin. inflammation and
Nursing interventions compromise gas
focus on improving exchange. Deep
oxygenation through breathing exercises help
deep breathing to expand lung capacity,
exercises, elevation of improve
the head of bed (HOB) ventilation-perfusion
to enhance lung matching, and facilitate
expansion, and clearance of respiratory
promoting airway secretions, thus aiding
clearance techniques in the restoration of
like coughing and effective gas exchange.
turning every 2 hours. Continuation of
Monitoring for signs antibiotics like
of respiratory distress, ampicillin-sulbactam
such as labored targets the underlying
breathing and infection, while
decreased breath discontinuing
sounds, is crucial, and unnecessary antibiotics
supportive measures like azithromycin
such as administering minimizes the risk of
Paracetamol for fever antibiotic resistance and
control may also be adverse effects. Nursing
necessary. interventions such as
Additionally, awaiting frequent vital sign
blood and sputum monitoring, elevation of
culture and sensitivity the head of the bed, oral
results guides hygiene maintenance,
antibiotic therapy and encouraging rest
adjustment for optimal and limited activity
management of the create an environment
 infection and gas conducive to respiratory
exchange impairment. recovery by reducing
stressors and promoting
optimal oxygenation.

Response: O2 is 95%, RR is 18, O2 is 95%, RR is 18,

not in respiratory not in respiratory
distress distress

Problem 3: Impaired Physical

Mobility related to
Neuromuscular
Involvement Secondary
to Stroke

S/O Data: Objective Data:

● D6
Azithromycin
● D3-4 Ampicillin
Sulbactam
● Asleep, easily
arousable
● (+) expressive
aphasia
● Follows
commands
● Pupils 2-3mm
● MMT
○ RUE: 0/5
○ RLE: 2/5
○ LUE: 5/5
○ LLE: 5/5
● No pedal edema
● GCS 11 (E4,
V1, M6)
● With right
hemiparesis
● Completely
assisted with
ADLs
● Cannot turn to
sides
independently

Manageme 5:30 AM (NEURO)

nt: ● Rounds done
● Continue
present
management
● Patient and
relatives
encouraged to
do passive ROM
exercises and
ankle pumping
exercises
● Please relay
result of KUBP
UTZ and attach
to chart
 12:15 PM (STROKE
SERVICES)
● Rounds done
● May remove
IFC
● May consume
IVF
● Continue PT/OT
while admitted
● Plan to
discharge after
completion of
antibiotics

2:34 PM (NEURO)
● Rounds done
with Dr.
Baroque
● To complete
antibiotics
● Continue PT/OT

4:36 PM (CV)
● Noted controlled
BP at
130-140/90
● If patient is for
rehab, no
objections from
cardiology
standpoint

Nursing Management:
Kept side rails up;
Provided a calm and
safe environment;
Encouraged passive
ROM exercises as
tolerated; Encouraged
adequate rest periods;
Assisted with
repositioning q2h

Rationale: These interventions are

crucial for a patient
with impaired physical
mobility related to
stroke because they
address various aspects
of care to promote
recovery and prevent
complications.
Encouraging passive
range of motion (ROM)
exercises and ankle
pumping exercises
helps maintain joint
flexibility, prevent
contractures, and
improve circulation.
Providing a calm and
 safe environment, along
with adequate rest
periods, supports the
patient's physical and
emotional well-being,
aiding in stress
reduction and
facilitating recovery.
Assisting with
repositioning and
keeping side rails up
help prevent falls and
provide stability, while
continuing physical and
occupational therapy
ensures ongoing
rehabilitation efforts to
maximize functional
independence. The
involvement of multiple
disciplines, as seen in
the communication
between neurology,
stroke services, and
cardiology, highlights
the comprehensive
approach to patient
care, addressing both
acute and long-term
needs.

Response: ● Able to tolerate

passive ROM
and
repositioning
● Still with
right-sided
weakness

Problem 4: Risk for Aspiration

related to use of NGT
secondary to dysphagia
and dysarthria

S/O Data: Objective Data:

● No dyspnea
● No cough
● No desaturations
● BP
130-140/70-80
● HR60-70
● T: 36.5
● O2: 98%
● No pedal edema
● GCS 12 (E4,
V2, M6)
● Pupils 2-3 mm
● (+) dysarthria
● (+) bibasal
crackles R>L
● Tolerated 3oz
 water test

Manageme 7:40 AM (NEURO)

nt: ● Rounds done
● Noted inputs
form other
services
● Refer

9:27 AM (NEURO)
● Rounds done
with Dr.
Baroque
● May give oral
tablets and
mashed potatoes
and bananas if
tolerated

11:40 AM (PULMO)
● Awaiting blood
culture result
● Continue oral
care TID

1:40 PM (PULMO)
● Shift ampicillin
sulbactam to
sultamicillin 750
mg/tab 1 tab
BID to complete
for 10 days (last
dose April 18,
2024, 8PM)

2:00 PM (CV)
● If for discharge,
no objections
from cardiology
standpoint
● Increase
spironolactone
to 50 mg/tab 1
tab PO OD
● Take home
medications to
follow

Nursing Management:
Elevate head of bed
during and after feeding;
Check for patency of
NGT prior to feeding;
Perform regular oral care;
Administer medications
as ordered (NAC 600
mg/tab 1 tab BID)

Rationale: These interventions are

implemented for
patients at risk for
aspiration due to
 dysphagia and
dysarthria to minimize
the chances of
pulmonary
complications.
Elevating the head of
the bed during and after
feeding helps prevent
reflux and aspiration by
utilizing gravity to aid
in swallowing and
digestion. Checking the
patency of the
nasogastric tube (NGT)
before feeding ensures
proper delivery of
nutrition and
medication without
causing aspiration.
Regular oral care
reduces the bacterial
load in the mouth,
decreasing the risk of
aspiration pneumonia.
Lastly, administering
medications as ordered,
such as
N-acetylcysteine
(NAC), can help
manage underlying
conditions contributing
to dysphagia and
dysarthria, thus
reducing the risk of
aspiration events.

Response: ● Able to tolerate

3 oz water test
● No episode of
aspiration
 Pathophysiology
Ultrasound
Sex (Male) Lack of Sleep Workplace Bilateral Renal Report: Renal Older Age (66) Previous History of
Stress Cortical Cysts Cortical Cysts, Smoking (30 years ago)
Bilateral

higher levels of sleep deprivation disrupts compression of the surrounding changes occur in the
testosterone compared to the normal circadian renal parenchyma structure and function of
hypothalamus in the brain
women rhythm blood vessels
detects stressors and chemicals in cigarettes,
signals the pituitary gland such as nicotine and
ischemia (reduced blood flow)
to release deposition of cholesterol, carbon monoxide, damage
causes increased and hypoxia (low oxygen levels)
adrenocorticotropic calcium, and other the endothelial cells lining
testosterone affects the sympathetic nervous in the affected areas of the
hormone (ACTH) O2 Sat: substances in the arterial the blood vessels
regulation of vascular system activity kidney
93-94% walls
tone
stimulates the adrenal kidney releases renin
elevated levels of stress glands
Carvedilol hormones such as cortisol blood vessels become
increased arterial stiffness
and adrenaline triggers the conversion of stiffer and less flexible inflammation and
angiotensinogen to angiotensin I endothelial dysfunction

progressive weakening
elevated blood pressure increased heart rate, angiotensin I converted to
and degeneration of blood
constricted blood vessels, angiotensin II
vessel walls
and mobilized energy vascular damage
reserves angiotensin II constricts blood exacerbates the risk of
Telmisartan
vessels formation of microbleeds and small
microaneurysms, small vessel rupture
stimulates the secretion of outpouchings or bulges in
Spironolactone aldosterone the vessel wall
increased blood pressure

sodium and water retention

rupture of
microaneurysms
increased blood volume and
blood pressure
LEGEND:
Predisposing
Main
Factors
Chronic Diagnosis
BP: 150/70
Hypertension
Precipitating
Factors
Treatments
Objective
persistently elevated blood pressure
Symptoms
(Labs, VS, Medications
Nicardipine drip Diagnostics)
increased peripheral resistance and Disease Process
the heart's pumping against this Risk for Impaired Skin Integrity related to Impaired Physical Mobility Related to Main Effects
resistance prolonged bed rest and reduced physical
Amlodipine Neuromuscular Involvement
mobility secondary to Acute Cerebral Secondary to Acute Cerebral Subjective Nursing
Hemorrhage Hemorrhage Symptoms
constant stress on the walls of blood Diagnosis
vessels, including the small arteries
and arterioles within the brain

Large Acute related to or as manifested by

blood vessels develop small
Intracerebral Hemorrhage
cause and effect
outpouchings or microaneurysms along with High Risk Hematoma
their walls
Expansion

rupture of microaneurysms CT Scan: Swirl sign

noted at the left
capsuloganglionic region
measuring 4.8 x 4.9 x
3.8 cm with volume of
activation of the clotting cascade 21.9 cc

Expressive Dysarthria GCS 12 (E4

Aphasia V2 M6)

hematoma clot forms within a cerebral

blood vessel

Neuro 8 capsule
affects Broca's area, associated with partially or completely obstruct the vessel
speech production and articulation

(+) Right central Middle Cerebral Artery damage brain tissue downstream from the occluded
facial palsy vessel does not receive an adequate
affects the primary motor cortex, controls
supply of oxygen and nutrients
movement of the body

(R) sided UE and LE Dizziness

weakness
accumulation of CSF within the ventricles
impacts the autonomic nervous system injury to the brainstem, the cortex, and the
Rehab Headache
(ANS) basal ganglia
(+) episodes
of loose watery increased intracranial pressure
stools dysregulation of gastrointestinal (GI) critical coordination of the muscle Mannitol
functions movements affected

Dysphagia stimulates chemoreceptor trigger zone

(+) urinary (CTZ), the vomiting center in the brain
incontinence IC difficulty swallowing
insertion
Bladder (+) 2 episodes of
training 6 nausea and vomiting vomiting, amounting to
cycles half a cup
NGT
weakened or uncoordinated swallowing insertion
movements

difficulty in propeling saliva and oral 3 oz

secretions from the mouth to the stomach Water Test

enters the airway instead of the esophagus Oral Care

through aspiration

entry of these substances into the

respiratory system
Azithromycin

foreign materials from oral cavity naturally

Ampicillin-Sulbactam
harbors various types of bacteria
Impaired Gas Exchange
Sultamicillin related to lung infiltrates
Pneumonia secondary to CAP-MR
(+) episodes
Paracetamol
of fever

accumulation of fluid and inflammatory compensatory response to hypoxia (low

exudates in the alveoli (small air sacs) inflammatory fluid and cellular debris triggers an immune response
oxygen levels) and impaired gas exchange
(+) bibasal
crackles R>L
ABG
alveoli collapses leading to the production more solid, dense appearance on imaging increased production of white blood cells
pH = ?7.49
of crackling sounds studies like X-rays or CT scans (WBC count)
pCO2 = 32.60
N-Acetylcysteine pO2 = ?69.30
HCO3 = 25.10 WBC count:
FiO2 = 21% Neutrophils = ?0.89
Radiological Report: consolidation
Uncompensated Segmenters = ?0.89
Interstitial infiltrates in both Respiratory Alkalosis
lower lung fields. Consider Lymphocytes = ?0.10
with hypoxemia on Monocytes = ?0.01
pneumonia room air
 NURSING CARE PLANS

NCP #1

Nursing Diagnosis: Impaired Gas Exchange related to lung infiltrates secondary to CAP-MR

Scientific Rationale: Stroke patients who acquire pneumonia, particularly those with CAP-MR, are prone to impaired
gas exchange due to lung infiltrates. This complication arises from a combination of factors including reduced mobility
leading to shallow breathing, aspiration risk due to dysphagia, and compromised immune function. Additionally, the
inflammatory response triggered by pneumonia exacerbates existing vascular and neural deficits, further compromising
respiratory function. Consequently, impaired gas exchange becomes a critical concern in stroke patients with pneumonia,
necessitating vigilant monitoring and targeted interventions to optimize oxygenation and prevent respiratory compromise.

Assessment Objectives Interventions Rationale Evaluation

Subjective: Goal: Independent Short Term

● No After the nursing
verbalizations interventions, the client Frequent monitoring Allows for early After 30 minutes of
from the will have been able to of vital signs and detection of changes nursing interventions,
patient improve gas exchange oxygen saturation in the patient's the client or caregiver:
and respiratory condition and ● Kept oxygen
Objective: function to maintain response to saturation
● CXR shows optimal oxygenation interventions. levels
lung and prevent further consistently
infiltrates in complications through Auscultate breath Reveals presence of above 95% on
bilateral treatment of sounds noting any congestion or room air.
lower lobes underlying cause adventitious breath collection of secretion, (patient)
● (+) labored which is pneumonia. sounds indicating need for ● Verbalized
breathing further intervention understanding
● Noted Objectives: of effective
decreased Observe skin color To determine coughing and
breath sounds Short Term and capillary refill circulatory adequacy, secretion
● (+) bilateral which is necessary for management
crackles and After 30 minutes of gas exchange to to prevent
rales upon nursing interventions, tissues respiratory
auscultation the client will have complication
Elevate head of bed Maintaining the
● VS as follows been able to: (caregiver)
patient in a
○ BP: ● Maintain ● Was able to
semi-Fowler's position
150/60 oxygen perform
optimizes lung
○ Temp: saturation effective deep
expansion and
36.6 C levels above breathing and
oxygenation
○ PR: 65 95% on room coughing
bpm air. (patient) techniques.
Oral hygiene Reduces the risk of
○ RR: 21 ● Ensure (client)
maintenance aspiration pneumonia
bpm effective deep ● Demonstrated
○ O2Sat: breathing and Advise adequate To prevent proper
93-94% coughing rest periods and overexhaustion and techniques for
techniques to limit activities reduces oxygen passive range
prevent consumption / of motion
respiratory demands exercises and
complications. repositioning
(patient and Encourage frequent Promotes optimal lung to optimize
caregiver) deep breathing, expansion and lung
● Demonstrate coughing exercises, drainage of secretions expansion.
proper and repositioning (caregiver)
techniques for
assisting with Provide a calm and Lessening external Long Term
passive range quiet environment stimuli helps in
of motion to allow client to promoting relaxation After 3 days of
exercises and relax and rest nursing intervention,
repositioning the client or caregiver:
the patient to ● Maintained
optimize lung stable
expansion. Dependent oxygenation
(caregiver) and
Administer Ensures adequate respiratory
Long Term supplemental oxygenation in cases status.
 oxygen as of hypoxemia (patient)
After 3 days of nursing prescribed in the ● Experienced
intervention, the client form of nasal no respiratory
will have been able to: cannula infections and
● Maintain complications
stable Administer Helps manage . (patient)
oxygenation medications as ongoing infection and ● Continued to
and respiratory ordered reduce viscosity of provide
status in the ● NAC 600 mucus adequate care
long run. mg/tab 1 tab and support
(patient) BID for the
● Prevent ● Ampicillin patient's
respiratory Sulbactam 1.5 respiratory
infections and g/IV in 90cc needs, with
complications. PNSS to run no signs of
(caregiver) for 1-2 hours caregiver
● Continue to q6 burnout or
provide ● Sultamicillin neglect.
adequate care 750 mg/tab 1 (caregiver)
and education tab BID for 10
to support the days
patient's
respiratory Collaborative/Interdependent
needs.
(caregiver) Consult with a Collaborate to
respiratory therapist optimize respiratory
treatments, including
chest physiotherapy,
supplemental oxygen
devices and
nebulization schedule

Coordinate with a Malnutrition may

dietitian reduce respiratory
mass and strength,
affecting muscle
function.

NCP #2

Nursing Diagnosis: Impaired Physical Mobility Related to Neuromuscular Involvement Secondary to Stroke

Scientific Rationale: Strokes, especially prevalent in individuals aged 60 and above, often lead to disabilities
exacerbated by age-related physiological changes like decreased muscle strength and tendon reflexes, balance difficulties,
and altered gait speed. Even healthy elderly individuals commonly experience impaired physical mobility due to
age-related changes. However, strokes can significantly worsen motor deficits, impacting both fine and gross motor
activities. Thus, their movements are slower. Due to motor disorders such as hemiplegia and paresis, they can present
progressive weakness and develop atrophy due to disuse, which increases difficulties resulting from a motor deficit and
generates additional disabilities even when turning sides in bed. (De Sousa Costa et al., 2010)

Assessment Objectives Interventions Rationale Evaluation

Subjective: Goal: Independent Short Term

● No After the nursing
verbalizations interventions, the client Monitor client for Can be indicated by After 8 hours of
from thewill be able to improve increased fatigue or sudden or constant nursing interventions,
patient his ability to perform weakness episodes of dizziness the client or caregiver:
activities of daily or exhaustion, ● Participated
Objective: living (ADLs) without especially depending in the
● GCS 11 (E4, or with minimal on the activity necessary
V1, M6) assistance. activities
● With right Keep side rails up To promote client prepared to
hemiparesis Objectives: safety and prevent help increase
● Completely falls or accidents activity
assisted with Short Term tolerance
 ADLs Assist client with To promote client ● Recalled and
● Cannot turn to After 8 hours of activities of daily safety restated signs
sides nursing interventions, living as appropriate and
independently the client or caregiver symptoms of
● MMT will have been able to: Assist client with To promote activity
○ RUE: 0/5 ● Express ROM and isometric circulation even upon intolerance
○ RLE: 2/5 willingness to exercises as rest, as well as allows ● Displayed
○ LUE: 5/5 participate in appropriate or for muscle tone, understanding
○ LLE: 5/5 the necessary tolerated contractility, and of the
activities to strength to be importance of
help increase maintained balancing
activity activities with
tolerance Observe and Clients who do not rest
(client) document client move frequently are
● Identify signs skin integrity susceptible to the Long Term
and symptoms formation of pressure
of activity ulcers After 3 days of
intolerance and nursing intervention,
when to seek Assist client with Maintaining the client:
help overall hygiene and cleanliness and ● Demonstrated
(caregiver) care daily hygiene is important an increase of
● Display to avoid infection, as tolerance to
understanding well as maintain skin activity
of the integrity within the
importance of level of
Advise client or Encourages client
balancing ability with
caregiver to report independence and
activities with the use of
onsets of symptoms awareness of their
rest (client) low-intensity
upon activity condition
● Demonstrate ROM
proper activities,
Instruct client to Quick or sudden
breathing proper
avoid quick and movements can
exercises breathing
sudden movements, predispose clients to
(client) exercises,
and to perform sudden episodes of
taking
activities gradually dizziness or nausea, or
Long Term intermittent
decreased blood
breaks during
pressure
After 3 days of nursing physical
intervention, the client Dependent activities, and
will have been able to: regular
● Take Administer wound These are necessary exercises
intermittent care treatments and for managing existing
breaks during dressings as ordered skin breakdown.
any physical (when necessary) Medications may also
activities be essential to treat
(client) skin issues when they
● Demonstrate arise.
an increase of
tolerance to Collaborative/Interdependent
activity as
evidenced by Collaborate with Collaborating with
the decrease of primary healthcare primary healthcare
weakness and providers on gradual providers allow for a
fatigue during increase of activity holistic approach to
activity (client) tolerance the client’s plan of
● Exercise care
regularly with
the use of Coordinate with To promote client
low-intensity Physical Therapy tolerance to activities
activities such
as passive
ROM
exercises
(client)
 NCP #3

Nursing Diagnosis: Risk for Impaired Skin Integrity related to prolonged bed rest and reduced physical mobility

Scientific Rationale: People who are unable to move much or who spend most of their time in bed have a higher risk of
developing skin damage. Rashes and sores can appear on the skin, particularly pressure wounds (also known as bed sores,
pressure sores, pressure ulcers, or decubitus ulcers). Stroke patients who are unable to frequently change positions to
relieve pressure are more likely to develop pressure ulcers than those who have limited physical mobility. The skin and
underlying tissues can become damaged when pressure is applied repeatedly to weak areas. Patients who have limited
movement may also encounter shear and friction forces when they are relocated or repositioned in bed. These forces may
put the skin under additional strain, which could lead to pressure sores. Last but not least, prolonged bed rest might result
in an increase in skin moisture as a result of things like sweating, fecal or urine incontinence, or wound exudate. The skin
becomes softer and more vulnerable to harm and deterioration when it is moist.

Assessment Objectives Interventions Rationale Evaluation

Subjective: Goal: Independent Short Term

Caregiver verbalized, After nursing
“Medyo namumula na interventions, the client Implement a turning Regular repositioning After 48-72 hours of
po yung sa may will have been able to and repositioning redistributes pressure, nursing interventions,
pwetan niya kasi po maintain intact and schedule preventing pressure the client or caregiver:
nabasa ng ihi at dumi healthy skin while ulcers. ● Had no new
niya.” preventing and pressure
managing impaired Maintain proper Keeping the skin clean ulcers
Objective: skin integrity despite skin hygiene and dry helps prevent develop.
● With right being on bedrest and moisture-related skin (patient)
hemiparesis having decreased breakdown. ● Established
● Completely physical mobility. clean and dry
assisted with Encourage use of These devices help skin.
ADLs Objectives: pressure-reducing distribute pressure (caregiver)
● With diaper devices (e.g., evenly, reducing the ● Showed no
● Cannot turn to Short Term specialized egg risk of pressure ulcers. signs of skin
sides crate mattresses, air breakdown
independently After 48-72 hours of bed and cushions) based on skin
● Dry skin nursing interventions, assessment
Assess skin Frequent assessment
● On bedsore the client or caregiver scales.
regularly, paying helps detect early
precaution will have been able to: (patient)
attention to signs of skin
● With turning ● Prevent ● Demonstrated
high-risk areas breakdown.
schedule pressure ulcers proper
every 2 hours from techniques for
Educate the Proper caregiver
● With slight developing. repositioning,
caregiver about skin education is crucial to
redness at (caregiver) turning and
care and ensure the patient
sacral area ● Maintain clean skin care.
repositioning receives adequate care
and dry skin. (caregiver)
and support.
(caregiver) ● Verbalized
● Monitor and Keep linens and Keeping linens and understanding
document skin beddings clean and beddings clean and and
condition dry dry helps prevent responded to
regularly. moisture buildup, signs of skin
(caregiver) reducing the risk of breakdown.
● Demonstrate skin irritation and (caregiver)
proper breakdown.
techniques for Long Term
repositioning, Assist in changing Assisting in changing
turning and of diaper diapers ensures timely After 2-4 weeks of
skin care. removal of soiled nursing intervention,
(caregiver) materials, preventing the client or caregiver:
● Recognize prolonged exposure to ● Had healed
signs of skin moisture and bacteria, any existing
breakdown and which can also skin redness
verbalize contribute to skin and
appropriate breakdown. developed
actions to take. healthier skin
(caregiver) Dependent condition.
(patient)
Long Term Administer wound These are necessary ● No new
care treatments and for managing existing pressure
 After 2-4 weeks of dressings as ordered skin breakdown. ulcers or skin
nursing intervention, (when necessary) Medications may also issues
the client or caregiver be essential to treat appeared in
will be able to: skin issues when they the long run.
● Promote the arise. (patient)
healing of any ● Remained
existing skin Collaborative/Interdependent comfortable
redness. all throughout
(caregiver) Implement a This involves and
● Prevent new multidisciplinary collaboration between experienced
pressure ulcers wound care team nurses, physicians, improved skin
and other skin wound care integrity for
issues over an specialists, and months at a
extended therapists to assess time. (patient)
period of time. and manage the
(caregiver) patient's skin integrity.
● Promote By pooling expertise
overall patient and resources, the
comfort and team can develop
well-being. tailored interventions,
(caregiver) such as specialized
dressings or therapies,
to prevent and treat
skin breakdown
effectively, promoting
optimal healing and
patient outcomes.

Collaborate with a Involvement of a

physical therapist physical therapist who
will recommend
exercises and mobility
strategies for the
patient is important to
minimize the risk of
skin breakdown.

Collaborate with a Involve a dietitian to

dietitian ensure the patient
receives proper
nutrition to support
skin health.

References:

De Sousa Costa, A. G., De Souza Oliveira, A. R., Alves, F. E. C., Chaves, D. B. R., Moreira, R.
P., & De Araújo, T. L. (2010). Diagnóstico de enfermagem: mobilidade física prejudicada
em pacientes acometidos por acidente vascular encefálico. Revista Da Escola De
Enfermagem Da USP, 44(3), 753–758.
https://doi.org/10.1590/s0080-62342010000300029