You are on page 1of 120

LYCEUM OF THE PHILIPPINES UNIVERSITY- BATANGAS

College of Nursing
Capitol Site, Batangas City
Presented By:
Alvarez, Nhicko V.
Atienza, Julius M.
Bagos, Ann Sherilyn
BSN 3-5

Presented To:
Ms. Sharon P. Remolana RN
(clinical Instructor)

Jan19 – 23, 2009 &


Feb 2 – 6, 2009
BATANGAS REGIONAL HOSPITAL
INTRODUCTION
Cerebrovascular disease is a group of brain dysfunctions
related to disease of blood vessels supplying the brain. Hypertension
is the most important cause that damages the blood vessel lining
endothelium exposing the underlying collagen where platelets
aggregate to initiate a repairing process which is not always complete
and perfect. Sustained hypertension permanently changes the
architecture of the blood vessels making them narrow, stiff, deformed
and uneven which are more vulnerable to fluctuations of blood
pressure. A fall in blood pressure during sleep can lead to marked
reduction in blood flow in the narrowed blood vessels causing
ischemic stroke in the morning whereas a sudden rise in blood
pressure can cause tearing of the blood vessels causing intracranial
hemorrhage during excitation at daytime. Primarily people who are
elderly, diabetic, smoker, or have ischemic heart disease, have
cerebrovascular disease. The results of cerebrovascular disease can
include a stroke, or even sometimes a hemorrhagic stroke.

A cerebrovascular disease is apparent if the victim displays


the following symptoms: dizziness, nausea, vomiting, severe
headaches, head pressure, and the numbness within the limbs,
slurred speech, vision loss, loss of coordination and the inability to
walk.
Cerebrovascular disease (CVD) is the third leading cause of
death after heart disease and malignancy and it is estimated that an
average of 500,000 new strokes will occur each year in the USA.
CVD is the most disabling of all neurologic diseases. Approximately
50% of survivors have a residual neurologic deficit and greater than
25% require chronic care. In Philippines, CVD has become one of the
greatest threats to the general health of the Filipino today. It is one of
the second leading causes of mortality in the Philippines. CVD, also,
has a prevalence of five per every one hundred adults in the country.
Moreover, it is more common on the middle age and old age adult
and occurs most commonly in the seventh decade of life. It is more
common in males than in females and also tends to run in the family.
It is a common complication of hypertension and atherosclerosis.
Meanwhile, this study is chosen due to various reasons. This study wouldn’t
be chosen without its significance. CVD, a disease entity, is a common
cause of morbidity and mortality in the country. Due to increasing prevalence,
there exists the necessity to be knowledgeable of such disease. Various
predisposing factors linger especially in above – forties, sedentary Filipinos,
and in various high – risk population groups. CVD having its own
complexities, classification, distinctive signs and symptoms, diagnostic
exams, treatment modalities, and prevention measures, is not a disease to
be taken for granted. It has been chosen also as our case because this is the
first time that we encounter this kind of disease and it is better for us to be
educated with its causative factors as well as the prevention and
management to decrease the mortality and morbidity of the patient whenever
CEREBROVASCULAR DISEASE occurs. As student nurses, we should
provide suitable nursing plans for patients with this kind of disease.
OBJECTIVES
General Objective:

Upon the completion of this case study, we aim to


acquire knowledge, skills and right attitude in the care of an
individual with CEREBROVASCULAR DISEASE – facts
about its nature that will enhance our comprehension that is
very imperative to provide a good nursing management to
our client.
Specific Objective
At the end of the study, the student nurses will be able to:

1.Introduce and understand Cerebrovascular Disease; its


description and definition.

2.Unfold and analyze the patient’s profile, past medical history,


as well as the family history, personal history, social history,
psychological history and the patient’s history of present illness
for further understanding his condition.
3. Assess the patient using Inspection, Palpation,
Percussion and Auscultation method that may help in
determining the clinical manifestation presented by the
disease.

4. Identify, interpret and analyze the laboratory and


diagnostic examination and its significant findings to
justify the presence of the disease.
5. Identify and enumerate the anatomical part of the body that
is involved and affected by the disease and its respective
functions.

6. Explain and identify the causes and predisposing factors


that contribute to the development of the disease.

7. Formulate and apply Nursing Care Plan for better delivery


of care based on the client’s needs and concerns.
8. Determine the drugs that were administered to the patient
and analyze its relevance in the treatment of the disease.

9. Note changes in the condition of the patient and the degree


of development of his condition

10. Discuss with the patient the discharge planning.


PATIENT’S PROFILE
NAME: Mrs. X
AGE: 52 years old
SEX: Female
DATE OF BIRTH: May 12, 1957
BIRTHPLACE: Albay
CIVIL STATUS: Married
OCCUPATION: Businesswoman and Laundry woman
ADDRESS: Muzon II, Alitagtag Batangas City
NATIONALITY: Filipino
RELIGION: Roman Catholic
DATE ADMITTED: January 17, 2009
TIME ADMITTED: 5:40 pm
DATE DISCHARGED: January 21, 2009
TIME DISCHARGED: 4:45 pm
ATTENDING PHYSICIAN: Dr. Brucal
CHIEF COMPLAINT: left sided body weakness
ADMITTING DIAGNOSIS: Cerebrovascular Disease probably infarct, right middle
cerebral artery distribution; Hypertension Stage II
FINAL DIAGNOSIS: Cerebrovascular disease, infarct right basal ganglia;
Hypertension Cardiovascular Disease; Community Acquired
Pneumoia
CLINICAL APPRAISAL
Past Health History
Mrs. X has been hospitalized for the first time in
Batangas Regional Hospital. According to her, it was her third
time to be hospitalized since her childhood. She has not had
any illness aside from cough and fever since birth. She can’t
remember if she completed her childhood immunization. She
has no known allergies to any drugs and foods. She was
never been involved in any accident and serious injuries. She
takes over – the – counter drugs for simple illnesses that she
usually acquires Paracetamol for fever, Neozep for colds,
Amlodipine for her BP and Mefenamic acid for pain relief.
Mrs. X is hypertensive and is currently taking
Amlodipine as her maintenance drug which is prescribed by
the doctor several moths ago but she stopped taking it due to
financial incapabilty.

Family History
Mrs. X, a 52 year old woman who owns a small
grocery store, is still living with her husband Mr. X, 65 year
old man who smokes and drinks alcoholic beverages
occasionally. Mr. & Mrs. X were blessed with 8 children.
Five boy ages 31, 30, 27, 25, 23 and three girls ages 29, 16
and 13. The common health problems their family encounters
are also common colds and fever. Their family and other
relatives are in good mental condition. They have no known
family history of heart disease, cancer, hypertension,
tuberculosis and diabetes mellitus.

Personal history
Mrs. X do smokes and drinks alcoholic beverages like
her husband ocassionally. She smokes 5 sticks per day. She
is fond of eating salty and fatty foods such as fried “sap -
sap”, “sinigang na baboy” and rarely fish and vegetables.
There is no specific pattern of rest and sleep since she is the
one who opens their store and fetch early in the morning for
the fruits that she is going to sell. She sleeps late at night and
wakes up early in the morning to prepare breakfast and
uniforms for her two daughters and opens her store.

Social History
Mrs. X is an elementary graduate. She was not able to
finish her secondary education due to financial problem; she
was only a first year high – school student when she stopped
studying. She got married at the age of 18. She has a good
attachment to her family. They always have time to bond and
share thoughts during weekends. Every Sunday, Mrs. X,
together with her husband and two daughters, attends mass
to praise and thank God for all the blessings that they
received. Mrs. X is a business woman but sometimes accepts
laundries while Mr. X is a baker.
According to Mrs. X, their monthly income is Php 5,000
which is not enough to meet their daily needs. Their house is
made mostly of wood. They live in a community where health
programs and services are implemented and are very
accessible. Mrs. X brings her children and grandchildren in
their Community Health Center for consultation and when
there is a health problem.
Their family is a typical Filipino family who had different
cultural beliefs in regarding their way of living. They believe in
the negative power like bad karmas and those unseen things in
this world that could hurt or cure them.

Psychological History
Her work as an owner of a mini grocery store and laundry
woman causes her to become stressful especially when she is
still working late at night because of the clothes that she is going
to wash and wakes up early in the morning to prepare uniforms
and foods for her two daughters. Financial constraint was also a
major stressor for her. Seeing her grandchildren happy and healthy
makes her happy.
History of Present Illness
Year 1999, Mrs. X was diagnosed with hypertension.
Even though she was diagnosed of hypertension, she did not
have any regular blood pressure monitoring in the community
because of too much busy. Four years after, year 2003, she
had experienced severe headache which led her to seek
consultation with increasing blood pressure that ranges from
190/120 mmHg and her normal blood pressure is just only
130/90 mmHg. She was diagnosed of CVD and was advised
for confinement in the hospital, Batangas Provincial Hospital.
She was confined for five days, and during her stay, she was
administered with anti – hypertensive drugs like Norvasc and
CalciBloc. She has recovered and the attending physician
gave Amlodipine, as her maintenance drug. Due to financial
incapability, she had no monthly check – up and cannot avail
her maintenance drug.
Two days, prior to admission at Martin Marasigan
Hospital, Mrs. X experienced nape pain associated with head
ache; but she just rest and ignored the symptoms. Early
morning, on January 13, 2009, Mrs. X experienced body
weakness after washing the clothes. Her son noticed slurring
of speech, so her husband brought her immediately at Martin
Marasigan Hospital for consultation.
There, she was managed as a case of CVD, HPN. She was
given Clonidine, Citecholine and Nicardipine. January 17,
2009, she was then transferred to Batangas Regional Hospital
for referral. Just before the admission at BRH, she had
sudden onset of left sided body weakness and loss of
consciousness and they immediately rushed the patient to
hospital at 5:40 pm. The resident on duty notified the
attending physician, Dr. Brucal, and made the admitting
diagnosis which is Cerbrovascular Disease ( CVD ).
PHYSICAL
ASSESSMENT
January 18, 2008

GENERAL APPEARANCE
Mrs. X looked weak in appearance and afebrile with
ongoing PNSS incorporated with Vit.B IV fluid in his right
hand regulated at 30 gtts per minute, awake, lying in bed,
experiencing difficulty of breathing and conscious when we
met her. She uses accessory muscle when breathing.

For his psychological presence, I noticed that she is


clean and neat.
VITAL SIGNS AND MEASUREMENTS

Blood Presssure - 180/130 mmHg


Temperature - 36.8 oC
Heart rate - 72 beats per minute
Respiratory rate - 19 breaths per minute
Height - 5”6 feet
BODY METHOD FINDINGS ANALYSIS
PART
Skin >Inspection >No lesion. >Normal.

>Palpation >No edema; skin rebounds and >Normal.


does not remain indented when
pressure is released.

>Warm to touch. >Normal.


>Normal.
>No tenderness. >Normal.

> With good skin turgor;


pinches easily and immediately
returns to its original position.
Head >Inspection >Head is still and >Normal.
upright and without
lesions.

>Palpation >Hard and smooth. >Normal.

>Absence of >Normal.
masses or nodules

a. Scalp >Inspection >Smooth and >Normal.


without lesion.

>Palpation >Absence of >Normal.


masses.

>Not tender >Normal.


b. Hair >Inspection
>Evenly distributed >Normal.

>No infestation. >Normal.


>Short black hair >Normal. Hair color
with few white – gradually changes
gray hairs. with age. The amount
of melanin in the hair
can decrease
causing hair to
become faded or
white. Gray hair
usually a mixture of
unfaded, faded and
white hairs.

>Palpation >Silky and strong. >Normal.

c. Face >Inspection >Rounded. >Normal.

>Symmetrical >Normal.
facial movements.
>Normal.
>Palpation >Absence of
nodule or masses
Eyes

a.Eyebrows >Inspection >Hair evenly >Normal.


distributed.

>Not meet at >Normal.


midline.

>Asymmetrically >Abnormal. This is


aligned in the left caused by the neurologic
part. impairment in CN III
(Occulomotor) which
leads to asymmetrical
alignment.

>Unequal >Abnormal. This is


movement. caused by the neurologic
impairment in CN III
(Occulomotor) which
leads to unequal
movement.
b.Eyelashes >Inspection >Equally distributed. >Normal.

c. Sclera >Inspection >With normal color >Normal.

d. Pupil >Inspection >PERRLA >Normal.

e. Eyelids >Inspection >Asymmetrically >Abnormal. This is


aligned in the left caused by the
part. neurologic impairment
in CN III (Occulomotor)
which leads to
asymmetrical
alignment.

>No abnormal >Normal.


discharge

f. Conjunctiva >Inspection >Pale palpebral >Abnormal. Due to


conjunctiva. inability of the lungs to
maintain adequate
oxygenation of blood.
Ears >Inspection >Symmetrically >Normal.
aligned.
>Normal.
>Smooth with no
lesion.

>No abnormal >Normal.


discharges.

>Palpation >Auricles are >Normal.


mobile, firm and not
tender.

>Pinna recoils after >Normal.


it is being folded
Nose >Inspection >No abnormal >Normal.
discharges.

>Symmetrically >Normal.
aligned.

>No flaring. >Normal.

a. Nasal >Palpation >No tenderness. >Normal.


Cavity

b. Sinus >Palpation >No tenderness. >Normal.


Mouth

a. Muscle >Inspection >Difficulty of >Abnormal. This is


tone opening the caused by the
mouth. neurologic impairment
in which leads to
decreased facial
muscle tone.

>Abnormal. This is
b. Speech >Inspection >Difficulty of caused by impaired
speaking Brocca’s area or the
speech center of the
brain.
Mouth

c. Lips >Inspection >Without lesion or >Normal.


swelling.

>Dry >Abnormal. This is due


to inadequate fluid
intake.

d. Teeth >Inspection >Absence of upper >Normal. Tooth enamel


teeth; presence of tends to wear away with
false teeth (upper age making the teeth
teeth). vulnerable to damage
and decay.

>With tooth decay >Abnormal. This is due


(Right 2nd and 3rd to acid produced by the
molars of the lower bacteria secondary to
teeth) and foul odor. the client’s inability to
maintain proper oral
hygiene.
e. Tongue >Inspection >Pink in color and >Normal.
moist.

>Moves freely >Normal.

>At midline >Normal.

>No lesion >Normal.

f. Gums >Inspection >Difficulty of >Abnormal. This caused


swallowing by the nuerologic
impairment.

g. Uvula >Inspection >Pink gums >Normal.

>Positioned at >Normal.
midline.

>Hangs freely >Normal.


Neck >Inspection >Symmetrically >Normal.
aligned with head
centered

>Palpation >Not tender >Normal.

a. Lymph >Palpation >No enlargement. >Normal.


node

b. Trachea >Palpation >Centered >Normal.


placement in
midline of neck.

c. Thyroid >Palpation >No enlargement. >Normal.


gland
Posterior
Thorax

-Shoulder >Inspection >Shoulder and back >Abnormal. This is


and back asymmetry at the left side. caused by the
impairment of the
right hemisphere.

Anterior
Thorax
- Chest and >Inspection >Regular rhythm >Normal.
Lungs.
>Within normal rate RR= 19 >Normal.
breaths per minute.

>Non – productive cough >Abnormal.


Continuous coughs
are usually
associated with
acute infections.
Anterior
Thorax
- Chest and >Inspection >Use of accessory >Abnormal. Sternum or
Lungs. muscles when shoulder muscles are
breathing. used to facilitate
inspiration in case of
pneumonia.

>Difficulty of >Abnormal. Gradual onset


breathing of dyspnea is usually
indicative of lung changes
such as pneumonia,
whereas sudden onset is
associated with bacterial
infections.

>Palpation >No tenderness is >Normal.


palpated over the lung
area with respirations.

>No unusual surface >Normal.


masses or lesions are
palpated.
Anterior
Thorax
- Chest >Auscultation >Crackles heard upon >Abnormal. Any condition
and Lungs. auscultation. where air hunger exists has the
potential to create audible and
noisy breathing. The body is
attempting to meet its oxygen
demands.

- Heart >Inspection >No lift or heave. >Normal.

>Auscultation >Within normal rate HR= >Normal.


82 beats per minute.

>No murmurs heard. >Normal.

- Abdomen >Inspection >Uniform in color. >Normal.

>Flat, rounded. >Normal.

>Auscultation >Active bowel sounds. >Normal.

>Percussion >Resonance >Normal.

>Palpation >Soft and not tender. >Normal.


Right Upper
Extremities
-Muscles >Inspection >Firm >Normal.
and
Palpation >Normal in size >Normal.

-Strength >Testing or >Able to grip >Normal.


(Right Hand) Inspection

-Circulation >Palpation >With distal pulse >Normal.


(Radial pulse)

>PR= 82 beats per >Normal.


minute.

-Hands >Inspection >Presence of IV >Abnormal. Fluids are


- PNSS regulated to replace
incorporated with losses.
Vit.B regulated at
30 ggts/minute
Left Upper
Extremities
-Muscles >Inspection >Lack of tone >Abnormal. It is due to the
and Palpation brain tissue damage in the
right hemisphere of the brain
manifesting in the left side of
the body.

-Strength >Testing or >Unable to grip and >Abnormal. It is due to the


(Left Hand) Inspection weakness was brain tissue damage in the
observed. right hemisphere of the brain
manifesting in the left side of
the body.

>Unable to move even >Abnormal. It is due to the


passive ROM. brain tissue damage in the
right hemisphere of the brain
manifesting in the left side of
the body.

-Circulation >Palpation >With distal pulse (Radial >Normal.


pulse)

>PR= 82 beats per >Normal.


minute
Fingers

-Nails >Inspection >Convex curvature >Normal.

>Smooth >Normal.

>Clean and >Normal.


groomed.

>Palpation >Hard and >Normal.


immobile

>Nail plate is >Normal.


attached to the nail
bed.

-Capillary >Palpation >Return of color >Abnormal. Due to


Refill – 5 seconds. inability of the lungs to
maintain adequate
oxygenation of blood.
Right Lower
Extremities

-Muscles >Inspection >Firm >Normal.


and
Palpation >Normal in size >Normal.

-Strength >Testing or >Able to move. >Normal.


Inspection

-Circulation >Palpation >With distal pulse. >Normal.


Left Lower
Extremities
-Muscles >Inspection >Lack of tone >Abnormal. It is due to the brain
and tissue damage in the right
Palpation hemisphere of the brain
manifesting in the left side of the
body.

-Strength >Testing or >Weakness >Abnormal. It is due to the brain


Inspection observed tissue damage in the right
hemisphere of the brain
manifesting in the left side of the
body.

>Palpation >Unable to >Abnormal. It is due to the brain


move even tissue damage in the right
passive ROM. hemisphere of the brain
manifesting in the left side of the
body.

-Circulation >With distal >Normal.


pulse
Genitalia
-Pubic >Inspection >Evenly Distributed >Normal.
Hair
>Normal.
-Female >Inspection >No abnormal
genitalia discharges.
>Normal.
>No lesions.

Neurologic
System

>LOC >Inspection >E= 4 (spontaneous); >Abnormal. The


M= 4 (flexes withdraws); client is lethargy
and due to the
V= 2 (incomprehensible alteration in mental
sounds) status because of
brain damage.
GCS= 10
SUMMARY OF PHYSICAL ASSESSMENT

Mrs. X, the subject of the study, is diagnosed with


Cerebrovascular Disease. Physical Appearance of the patient
was assessed through inspection, palpation, percussion and
auscultation. This will serve as a baseline guide to recognize
the signs and symptoms of the disease. There were
abnormalities found on her.

Upon admission Mrs. X’s Vital Signs were all stable


expect for her BP. She is experiencing difficulty of breathing
when we met her. Gradual onset of dyspnea is usually
indicative of lung changes such as pneumonia, whereas
sudden onset is associated with bacterial infections. Use of
accessory muscles when breathing was also noticed. Sternum
or shoulder muscles are used to facilitate inspiration in case of
pneumonia. Non - productive cough noted and is often
associated with acute infections.

She has short black with few white – gray hairs and
hair color gradually changes with age. The amount of melanin
in the hair can decrease causing hair to become faded or
white. Gray hair usually a mixture of unfaded, faded and white
hairs. We noticed that her eyebrow in the left part is
asymmetrically aligned and the movement is not equal. These
conditions are caused by the neurologic impairment in CN III
(Occulomotor). Her eyelids in the left part is also
asymmetrically aligned and this caused also by the neurologic
impairment in CN III (Occulomotor).

Upon inspecting her conjunctiva, we found out that it


was pale. This is due to inability of the lungs to maintain
adequate oxygenation of the blood. Upon inspecting her
mouth, we noticed that her lips were dry and dry lips indicate
dehydration which is due to inadequate fluid intake. Absence
of upper teeth and presence of false teeth were also noticed.
Tooth enamel tends to wear away with age making the teeth
vulnerable to damage and decay. She has tooth decay in the right 2nd and
3rd molars in her lower teeth and foul odor was noticed. This is due to acid
produced by the bacteria secondary to the client’s inability to maintain
proper oral hygiene. Mrs. X is experiencing difficulty of opening the mouth
and swallowing. This is caused by the neurologic impairment. She is also
experiencing difficulty of speaking and this is caused by impaired Brocca’s
area or the speech center of the brain.

Upon assessing for her posterior and anterior thorax, her shoulder
and back are asymmetry at the left side. This is caused by the impairment
of the right hemisphere. Crackles were heard upon auscultation because
there is sudden opening of small airways that contain fluid. Any condition
where air hunger exists has the potential to create audible and
noisy breathing. The body is attempting to meet its oxygen
demands.

For her upper extremities, especially the left part, there


is lack of tone of the muscles and she can’t able to grip and
move even passive ROM. This is due to the brain tissue
damage in the right hemisphere of the brain manifesting in the
left side of the body. Presence of IV her right hand – PNSS
incorporated with Vit.B regulated at 30 ggts/minute – was also
noticed. Fluids are regulated to replace losses. We did
capillary testing to Mrs. X; the result was the color return to its
original color after 5 seconds. This is due to inability of the
lungs to maintain adequate oxygenation of blood.

For her lower extremities, left part also, there is lack of


tone of the muscles, weakness was observed and unable to
move even passive ROM. This is due to the brain tissue
damage in the right hemisphere of the brain manifesting in the
left side of the body.

Lastly, upon assessing for the neurologic system, her


GCS was 10. The client is lethargy due to the alteration in
mental status because of brain damage.
DIAGNOSTIC
AND
LABORATORY RESULTS
HEMATOLOGY DATE TAKEN: January 18, 2009

TEST RESULT NORMAL VALUES ANALYSIS


EXAMINATION

Erythrocytes 4.95 x 1012/L 4.2 – 5 x 1012/L Normal.

Hemoglobin 136.8 g/dL 120 – 140 g/dL Normal.

Hematocri 0.426 % 0.38 – 0.47 % Normal.

Leukocyte 6.89 x 109/L 4.5 – 11 x 109/L Normal.

>Neutrophil 63 % 54 – 75% Normal.

>Eosinophil 0.067 % 0.01 – 0.08% Normal.

> Basophil 0.002 % 0.0 – 0.01% Normal.

>Lymphocyte 0.238 % 0.25-0.4% Normal

>Monocytes 0.063 % 0.02-0.08% Normal.


HEMATOLOGY DATE TAKEN: January 18, 2009

TEST RESULT NORMAL ANALYSIS


EXAMINATION VALUES

Platelets 302 x 109/L 150 – 400 x 109/L Normal.

MCH 27.64 pg 27 – 31 pg Normal.

MCV 86.14 fl 80 – 96 fl Normal.

MCHC 0.34 0.32 – 0.36 Normal.

RDW 12.9% 11.6 – 13.7% Normal.

MPV 8.3 fl 7.8 – 11 fl Normal.


CHEMISTRY DATE TAKEN: January 18, 2009
TEST RESULT NORMAL VALUES ANALYSIS
EXAMINATION

Abnormal.
Elevated glucose
Glucose 7.18 mmol/L 3.88 – 5.83 mmol/L level may indicate
that Mrs. X has a
possible diabetes
mellitus.

Abnormal.
Decreased BUN
BUN 3.15 mmol/L 6.26 – 8.33 mmol/L level may indicate
a possible
malnutrition and
over hydration.

Creatinine 62.9 umol/L 53.1 – 115.0 umol/L Normal.


CHEMISTRY DATE TAKEN: January 18, 2009
TEST RESULT NORMAL ANALYSIS
EXAMINATION VALUES

Cholesterol 7.19 0.0 – 5.2 Abnormal. Elevated cholesterol level


mmol/L mmol/L indicates acute myocardial infarction.

Triglyceride 1.63 0.68 – 1.33 Abnormal. Elevated triglyceride level


mmol/L mmol/L indicates acute MI and hypertension.

HDL 1.67 mg/dL 1.09 – 2.29 Normal.


mg/dL

Sodium 152 mmol/L 135 - 148 Abnormal. Elevated sodium level


mmol/L /hypernatremia might be caused by
anuria due to acute renal failure.

Potassium 4.08 3.5 – 5.5 Normal.


mmol/L mmol/L

LDL 6.53 1.98 – 5.67 Abnormal. Elevated LDL level


mmol/L mmol/L indicates acute MI and hypertension.
URINALYSIS DATE TAKEN: January 18, 2008

TEST EXAMINATION RESULT NORMAL ANALYSIS


VALUES

Color Light yellow Straw , amber Normal.


transparent

Character Slightly turbid Clear Abnormal. May indicate urinary tract infection.

Specific Gravity 1.015 1.005 – 1.035 Normal.

Reaction 6.5 N/A N/A

Albumin (-) (-) Normal.

Sugar (-) (-) Normal.

Microscopic Exam

Pus Cell 0-1 1–2 Normal.

RBC None seen None seen Normal.


CHEMISTRY DATE TAKEN: January 19, 2009

TEST RESULT NORMAL ANALYSIS


EXAMINATI VALUES
ON

Glucose 5.73 3.88 – 5.83 Normal.


mmol/L mmol/L

Sodium 143.5 135 - 148 Normal.


mmol/L mmol/L

Potassium 3.7 mmol/L 3.5 – 5.5 Normal.


mmol/L
DATE TAKEN: January 17, 2009

CHEST X-RAY

Findings:

Lung fields are clear. Heart is magnified. Aorta is


calcified. Other, chest structures are not remarkable.

Impression:

> Clear lung fields.


> Magnified Heart.
> Atheromatous aorta.
SUMMARY OF DIAGNOSTIC
AND LABORATORY RESULTS
As the laboratory exam for the hematology released last
January 18, 2009, we found out that all of the findings were normal.
Next laboratory exam is the blood chemistry which is also done on
the same day; we found some abnormalities. The glucose,
cholesterol, triglyceride and sodium level were elevated as well as
the LDL level. The BUN level was decreased.

January 19, 2009, the blood chemistry was again done to


Mrs. X. The glucose, cholesterol, BUN, triglyceride, sodium and LDL
levels were back to its stable state or normal state.
Chest X – ray was also done to Mrs. X last January 17,
2009 and it reveals that lung fields are clear, heart is
magnified and aorta is calcified.

Other findings were all normal.


ANATOMY
AND
PHYSIOLOGY
Brainstem - The lower extension of the brain where it connects to the
spinal cord. Neurological functions located in the brainstem include those
necessary for survival (breathing, digestion, heart rate, blood pressure)
and for arousal (being awake and alert).

Most of the cranial nerves come from the brainstem. The brainstem is the
pathway for all fiber tracts passing up and down from peripheral nerves
and spinal cord to the highest parts of the brain.

Cerebellum - The portion of the brain (located at the back) which helps
coordinate movement (balance and muscle coordination). Damage may
result in ataxia which is a problem of muscle coordination. This can
interfere with a person's ability to walk, talk, eat, and to perform other self
care tasks.
Frontal Lobe - Front part of the brain; involved in planning, organizing,
problem solving, selective attention, personality and a variety of "higher
cognitive functions" including behavior and emotions.

The anterior (front) portion of the frontal lobe is called the prefrontal cortex.
It is very important for the "higher cognitive functions" and the
determination of the personality.

The posterior (back) of the frontal lobe consists of the premotor and motor
areas. Nerve cells that produce movement are located in the motor areas.
The premotor areas serve to modify movements.

The frontal lobe is divided from the parietal lobe by the central culcus.
Occipital Lobe - Region in the back of the brain which processes visual
information. Not only is the occipital lobe mainly responsible for visual reception, it
also contains association areas that help in the visual recognition of shapes and
colors. Damage to this lobe can cause visual deficits.

Parietal Lobe - One of the two parietal lobes of the brain located behind the frontal
lobe at the top of the brain.

Parietal Lobe, Right - Damage to this area can cause visuo-spatial deficits (e.g.,
the patient may have difficulty finding their way around new, or even familiar,
places).

Parietal Lobe, Left - Damage to this area may disrupt a patient's ability to
understand spoken and/or written language.
The parietal lobes contain the primary sensory cortex which controls sensation
(touch, pressure). Behind the primary sensory cortex is a large association area
that controls fine sensation (judgment of texture, weight, size, shape).

Temporal Lobe - There are two temporal lobes, one on each side of the brain
located at about the level of the ears. These lobes allow a person to tell one smell
from another and one sound from another. They also help in sorting new
information and are believed to be responsible for short-term memory.

Right Lobe - Mainly involved in visual memory (i.e., memory for pictures and
faces).

Left Lobe - Mainly involved in verbal memory (i.e., memory for words and names).
Brain Structures and their Functions
Cerebrum
Cerebellum
Limbic System
Brain Stem

The nervous system is your body's decision and communication center. The central
nervous system (CNS) is made of the brain and the spinal cord and the peripheral nervous
system (PNS) is made of nerves. Together they control every part of your daily life, from
breathing and blinking to helping you memorize facts for a test. Nerves reach from your brain
to your face, ears, eyes, nose, and spinal cord... and from the spinal cord to the rest of your
body. Sensory nerves gather information from the environment, send that info to the spinal
cord, which then speed the message to the brain. The brain then makes sense of that
message and fires off a response. Motor neurons deliver the instructions from the brain to the
rest of your body. The spinal cord, made of a bundle of nerves running up and down the
spine, is similar to a superhighway, speeding messages to and from the brain at every
second.
The brain is made of three main parts: the forebrain, midbrain, and
hindbrain. The forebrain consists of the cerebrum, thalamus, and hypothalamus
(part of the limbic system). The midbrain consists of the tectum and tegmentum.
The hindbrain is made of the cerebellum, pons and medulla. Often the midbrain,
pons, and medulla are referred to together as the brainstem.

The Cerebrum: The cerebrum or cortex is the largest part of the human brain,
associated with higher brain function such as thought and action. The cerebral
cortex is divided into four sections, called "lobes": the frontal lobe, parietal lobe,
occipital lobe, and temporal lobe. Here is a visual representation of the cortex:

Note that the cerebral cortex is highly wrinkled. Essentially this makes the brain
more efficient, because it can increase the surface area of the brain and the
amount of neurons within it. We will discuss the relevance of the degree of cortical
folding (or gyrencephalization) later.
A deep furrow divides the cerebrum into two halves, known as
the left and right hemispheres. The two hemispheres look
mostly symmetrical yet it has been shown that each side
functions slightly different than the other. Sometimes the right
hemisphere is associated with creativity and the left
hemispheres is associated with logic abilities. The corpus
callosum is a bundle of axons which connects these two
hemispheres.
The Cerebellum: The cerebellum, or "little brain", is similar to the
cerebrum in that it has two hemispheres and has a highly folded surface or
cortex. This structure is associated with regulation and coordination of
movement, posture, and balance.

The cerebellum is assumed to be much older than the cerebrum,


evolutionarily. What do I mean by this? In other words, animals which
scientists assume to have evolved prior to humans, for example reptiles,
do have developed cerebellums. However, reptiles do not have neocortex.

Limbic System: The limbic system, often referred to as the "emotional


brain", is found buried within the cerebrum. Like the cerebellum,
evolutionarily the structure is rather old.
This system contains the thalamus, hypothalamus, amygdala, and hippocampus.
Here is a visual representation of this system, from a midsagittal view of the human
brain:

Thalamus - a large mass of gray matter deeply situated in the forebrain at the
topmost portion of the diencephalon. The structure has sensory and motor
functions. Almost all sensory information enters this structure where neurons send
that information to the overlying cortex. Axons from every sensory system (except
olfaction) synapse here as the last relay site before the information reaches the
cerebral cortex.

Hypothalamus Amygdala- part of the telencephalon, located in the temporal lobe;


involved in memory, emotion, and fear. The amygdala is both large and just
beneath the surface of the front, medial part of the temporal lobe where it causes
the bulge on the surface called the uncus. This is a component of the limbic system
Amygdala Hypothalamus- part of the diencephalon, ventral to the
thalamus. The structure is involved in functions including homeostasis,
emotion, thirst, hunger, circadian rhythms, and control of the autonomic
nervous system. In addition, it controls the pituitary.

HippocampusHippocampus- the portion of the cerebral hemisphers in


basal medial part of the temporal lobe. This part of the brain is important
for learning and memory . . . for converting short term memory to more
permanent memory, and for recalling spatial relationships in the world
about us
The brain stem is made of the midbrain, pons, and medulla.

Midbrain/ Mesencephalon- the rostral part of the brain stem, which includes the tectum and
tegmentum. It is involved in functions such as vision, hearing, eyemovement, and body
movement. The anterior part has the cerebral peduncle, which is a huge bundle of axons
traveling from the cerebral cortex through the brain stem and these fibers (along with other
structures) are important for voluntary motor function.

Pons- part of the metencephalon in the hindbrain. It is involved in motor control and sensory
analysis... for example, information from the ear first enters the brain in the pons. It has parts
that are important for the level of consciousness and for sleep. Some structures within the
pons are linked to the cerebellum, thus are involved in movement and posture.

Medulla Oblongata- this structure is the caudal-most part of the brain stem, between the
pons and spinal cord. It is responsible for maintaining vital body functions, such as breathing
and heartrate
pathophysiology
NON- MODIFIABLE FACTOR MODIFIABLE FACTOR

52 YEARS OLD Socioeconomic status

FEMALE OCCUPATION
>In females, the weak branching points of arteries give rise to >Business woman & laundry woman
protrusions with a very thin covering of endothelium that can
tear o bleed easily rise of BP
Stress

LIFESTYLE
>Drinks alcohol occasionally & smoking 5 sticks of cigarettes a day

DIET
>high in fats and high in sodium

Failure to comply with her maintenance


antihypertensive drug (Amlodipine) and
failure to have a regular BP monitoring

Fatty deposits build up on the inner wall of an artery (Aterosclerosis)

Formation of a clot inside the blood vessel (thrombosis)

Disruption of cerebral blood flow

Ischemic Stroke

Left side paralysis[hemiplegia] Loss of coordination Loss of balance Inability to walk Numbness/weakness Change of alertness
(Weakening of the (Lethergy)
receptors in the body)

Headache when lying flat Difficulty speaking


and
swallowing
SUMMARY OF PATHOPHYSIOLOGY
Mrs. X has been diagnosed of CVD. These are the predisposing
factors that contributed to the client’s illness such as sex (female), increased
age (52 years old), socio – economic status, stress, occupation (business
woman and laundry woman), diet (high in fat and sodium), and lifestyle
(drinks alcohol occasionally and smoking of 5 sticks per day) and the client’s
negative behavior towards taking the necessary precautions and preventive
measures like failure to have a regular BP monitoring and the failure to
comply with the medications due to financial incapability.
Cigarette smoking, alcohol drinking and consumption of unhealthy
foods which are high in fat and sodium are one of the key players in
developing Hypertension. Due to high BP combined with the clients’
increased age, injuries in the intima or inner layer of the arterial blood
pressure vessels can happen. The strong turbulence created by high BP
causes the destruction of the inner lining of the arterial vessels wich are less
elastic due to aging. Moreover, the nicotine due to smoking is deposited in the intima.
As we mentioned earlier, our patient is a female, wherein females, the weak
branching points of arteries give rise to protrusions with a very thin covering of
endothelium that can tear or bleed easily rise BP. These factors and conditions lead
to the development of atherogenesis that leads to building up of fatty deposits in the
inner of an artery called the atherosclerosis. This formation of fatty deposits may lead
to the formation of clot (thrombosis) inside the blood vessels.
There is a disruption of a blood flow initiates a complex series of cellular
metabolic events called Ischemic stroke. Left side paralysis or hemiplegic leads to
weakening of the receptors of the body, loss of coordination, loss of balance, Inability
to walk, Numbness/weakness, Change of alertness(Lethergy), Headache when lying
flat, Difficulty speaking, Difficulty of swallowing and Decreased vision are the clinical
manifestations that occur to our patient having Cerebrovascular Disease specifically
CVA or Ischemic Stroke.
NURSING CARE
PROCESS
ASSESSMENT NURSING SCIENTIFIC PLANNING
DIAGNOSIS EXPLANATION

Subjective cues: Ineffective airway The inflammatory After 4 hours of


“ Medyo nahihirapan clearance related response to infection nursing
pa akong huminga”. to ineffective causes tissue edema interventions, the
cough and and exudates formation client will be able
Objective cues: retained in the lungs, the to maintain
> Use of accessory secretions. inflammatory response airway patency.
muscles when breathing can narrow and
>crackles herad upon potentially obstruct
percussion bronchial passages and
>productive cough – alveoli.
whitish color (Medical- Surgical
>dyspneic Nursing Critical Thinking
>difficulty of vocalizing for collaborative care,
>restlessness vol.1,5th edition,
Ignatius, et.al,page 978)
INTERVENTION RATIONALE

>Assessed respiratory >Use of accessory muscles to breathe indicates an abnormal


movements and use of increase in work of breathing. (Nursing Care Plan, 6th edition,
accessory muscles. Gulanick/Myers pg. 480)

>Monitored vital signs >To obtain baseline data. (Pediatric Nursing Care Plans, 3rd
especially the RR. edition,Karla L. Luxner,RNC,ND,pg. 67)

>Auscutated the lung >Bronchial lung sounds are commonly heard over areas of lung
sounds, noting areas of density or consolidation. Crackles are heard when fluid is present.
decreased ventilation and (Nursing Care Plan, 6th edition, Gulanick/Myers pg. 480)
presence of adventitious
sounds.

>Monitored chest x – ray >These determine progression of disease process. (Nursing Care
reports. Plan, 6th edition, Gulanick/Myers pg. 480)
INTERVENTION RATIONALE

>Encouraged client to >Hydration helps decrease the viscosity of secretions, facilitating


increase fluid intake. expectorations. (Pediatric Nursing Care Plans, 3rd edition,Karla L.
Luxner,RNC,ND,pg. 67)

>Advised the realtives >Positioning facilitates chest expansion and respiratory efficiency
elevate the head of bed at by reducing pressure of abdominal organs on diaphragm. (Pediatric
least 30 degrees. Nursing Care Plans, 3rd edition,Karla L. Luxner,RNC,ND,pg. 68)

>Assisted on nebulizer > Relaxes bronchial and uterine smooth muscle by acting on beta –
treatment. Nebulization adrenergic receptors. (MIMS page 345)
done as per doctor’s order
every 12 hours.

>Chest tapping performed >Chest physiotherapy helps to aid immobilization of secretions.


after each nebulization. (Nursing Care Plan,7th edition, Doenges, et.a pg 108l)
INTERVENTION RATIONALE

>Instructed the client to >Discharges from the nebulizer are often foul tasting and
have oral care after smelling. (Nursing Care Plan, 6th edition, Gulanick/Myers
each nebulization. pg. 480)

>Provided >Fluids are regulated to replace losses and aid


supplemental fluids immobilization secretions.(Nursing Care Plan,7th edition,
-IV- D5 0.3 NaCl Doenges, et.a pg 108l)
500cc regulated at 30
mcgtts per minute a per
doctor’s order.
INTERVENTION RATIONALE EVALUATION

>Instructed the >Discharges from the nebulizer are The client maintained
client to have oral often foul tasting and smelling. airway patency as
evidenced by
care after each (Nursing Care Plan, 6th edition, expectorating clear
nebulization. Gulanick/Myers pg. 480) secretions readily.

>Provided >Fluids are regulated to replace losses


supplemental fluids and aid immobilization
-IV- D5 0.3 NaCl secretions.(Nursing Care Plan,7th
500cc regulated at edition, Doenges, et.a pg 108l)
30 mcgtts per
minute a per
doctor’s order.
ASSESSMENT NURSING SCIENTIFIC PLANNING
DIAGNOSIS EXPLANATION

Subjective cues: Impaired physical Deprivation of oxygen After 3 days of


“ Mabigat at ngimay pa mobility related to supply of the brain tissue nursing
din ang pakiramdam ng hypotonic may result to nerve interventions,
kaliwang kamay at paa ko”. paralysis of left damage which may affect the client will be
side of the body the individual’s able to improve
Objective cues: secondary to sensorimotor ability that and increase
> patient is bedridden decreased may result to limitation of strength and
>limited range of motion oxygenation of the independent, function of
observed the right side of purposeful movement of affected and
>uncoordinated movements the brain. the body or of one or compensatory
observed more extremities. body parts.
>inability to move the left
upper and lower extremities (Medical- Surgical
observed Nursing Critical Thinking
>restlessness noted for collaborative care,
>dependent and unable to vol.1,5th edition, Ignatius,
participate in activity et.al, page 2340 )
>difficulty in turning
INTERVENTION RATIONALE

>Monitored vital signs. >Establishes baseline data for review of existing


conditions. (Nursing Care Plan, 6th edition,
Gulanick/Myers pg. 561)

>Monitored and recorded >This information is used to determine and prevent life –
neurological status using Glasgow threatening complications such as severe hypertension
Coma Scale. and increased ICP. (Nursing Care Plan, 6th edition,
Gulanick/Myers pg. 561)

>Monitored intake and output and >Because of cerebral edema, fluid balance must be
specific gravity. regulated. Fluids may be restricted if the patient has
significant increase in ICP. (Nursing Care Plan, 6th
edition, Gulanick/Myers pg. 562)

>Assisted the client in repositioning >Helps the client in performing ADL’s. (Nursing Care
herself. Plan, 6th edition, Gulanick/Myers pg. 562)

>Provided safety measures such >Enhances safety. (Nursing Care Plan, 6th edition,
as putting pillow on bedside of the Gulanick/Myers pg. 562)
patient to prevent fall.

>Taught perform active ROM >Active ROM increases muscle mass, tone and strength
exercises on unaffected limbs and improves cardiac and respiratory functioning.
within levels of patient’s tolerance. (Nursing Care Plan, 6th edition, Gulanick/Myers pg. 563)
INTERVENTION RATIONALE

>Performed passive ROM in affected limbs at >A voluntary muscle will lose tone and
least three to four times daily. Exercises are strength and becomes shortened from
done slowly to allow the muscles time to relax, reduced range of motion or lack of exercise.
and support the extremity above and below (Nursing Care Plan, 6th edition,
the joint to prevent strain on joints and Gulanick/Myers pg. 563)
tissues. Stopped point when pain and
resistance is met.

>Scheduled activities with adequate rest >Reduces fatigue and maximizes energy
periods during the day. production. (Nursing Care Plan, 6th edition,
Gulanick/Myers pg. 563)

>While the client is in bed, the following steps >Prolonged immobility and impaired
were performed to maintain alignment: neurosensory function can cause permanent
contractures. (Nursing Care Plan, 6th edition,
Gulanick/Myers pg. 564)

a. Used pillows to serve as footboard. >This measure helps prevent foot drop.
(Nursing Care Plan, 6th edition,
Gulanick/Myers pg. 564)

b. Avoided prolonged periods of sitting or >This measure prevents hips flexion


lying in the same position. contractures. (Nursing Care Plan, 6th edition,
Gulanick/Myers pg. 564)
INTERVENTION RATIONALE
c. Changed position of shoulder joints >This measure prevents shoulder contractures.
every 2 hours. (Nursing Care Plan, 6th edition, Gulanick/Myers
pg. 564)

d. Used a pillow when on Fowler's position >This measure prevents flexion contracture of the
placed on the back of the head. neck. (Nursing Care Plan, 6th edition,
Gulanick/Myers pg. 564)

e. When client is in lateral position, placed >This measure prevents internal rotation and
pillows to support the leg from groin to adduction of the femurs and hip and also internal
foot and a pillow to flex the shoulder adduction of shoulder. (Nursing Care Plan, 6th
and elbow slightly. edition, Gulanick/Myers pg. 564)

>Provided progressive mobilization by >Prolonged bed rest can cause a sudden drop in
maintaining head of bed at least 30 blood pressure (orthostatic hypotension) as blood
degree angle and assisted the client returns to peripheral circulation. (Nursing Care
slowly from lying to sitting position. Plan, 6th edition, Gulanick/Myers pg. 565)
INTERVENTION RATIONALE EVALUATION

>Kept the patient’s >This position promotes venous The client was able to
head and neck in drainage from the brain and maintain and increase
strength and function of
neutral position. decreases ICP. (Nursing Care affected and
Plan, 6th edition, Gulanick/Myers compensatory body part
as evidenced by:
pg. 565)
> Increased ROM such as
turning from side to side
>Avoided >Frequent stimulation of the patient as observed.
unnecessary care increases brain activity and ICP.
> Able to move her hand
activities. Clustering care activities in a short as response
period of time also increases ICP.
> Able to flex extremities
(Nursing Care Plan, 6th edition, with assistance from the
Gulanick/Myers pg. 565) relatives.
ASSESSMENT NURSING SCIENTIFIC EXPLANATION
DIAGNOSIS

Subjective cues: Impaired verbal A CVD, which may be caused by,


“ Nahihirapan siyang communication hemorrhage, thrombus, embolism or
umimik”, as verbalized by the related to vasospasm, can result in a local area of cell
relative. alteration of death, called infarct. It is caused by a lack of
motor speech blood supply which is then surrounded by
Objective cues: area of the brain an area of cells that are secondarily
> non – verbal response affected. Since symptoms depend on the
when asked location of the stroke and size of the
> difficulty of forming words infarct, it could involve the brain’s Brocca’s
noted area, which is primary responsible for
communication through facial expressions
> LOC - lethargy
and speech. By causing damage to this
> GCS= 10 area, the patient’s communicating skills are
>restlessness noted greatly altered and affected.
(Medical- Surgical Nursing, vol.2,9th edition,
Brunner & Suddarths, page 1259 )
PLANNING

After 3 days of nursing


interventions, the client
will establish method of
communication in which
needs can be expressed
INTERVENTION RATIONALE
>Monitored vital signs with emphasis >Establishes baseline data for review of
to BP. existing conditions. (Nursing Care Plan, 6th
edition, Gulanick/Myers pg. 565)

>Provided an atmosphere of >Impaired ability to communicate


acceptance and privacy through spontaneously is frustrating and
speaking slowly and in a normal embarrassing. Nursing actions should focus
tone, not forcing the client to on decreasing the tension and conveying an
communicate. understanding of how difficult the situation
must be for the client. (Nursing Care Plan,
6th edition, Gulanick/Myers pg. 565)

>Deliberate actions can be taken to improve


>Taught techniques to improve speech. As the client’s speech improves, his
speech by initially asking confidence will increase and she will make
questions that client can answer more attempts at speaking. (Nursing Care
with a “yes” or “no”. Plan, 6th edition, Gulanick/Myers pg. 565)
INTERVENTION RATIONALE
>Used strategies to improve the >Improving the client’s comprehension
client’s comprehension by can help to decrease frustration and
using touch and behavior to increase trust. Clients with aphasia can
communicate calmness and correctly interpret tone of voice.
adding other non – verbal (Nursing Care Plan, 6th edition,
methods of communication Gulanick/Myers pg. 566)
such as pointing or using flash
cards for basic needs; using
pantomime; or using paper
and pen.
>Involved the significant others in >Enhances participation and
the plan of care. commitment to plan. (Nursing Care
Plan, 6th edition, Gulanick/Myers pg.
566)

>Imparts thought and answers the


>Educated relatives to establish a needs of the client with lessened
method of communication difficulty. (Nursing Care Plan, 6th
through sign language. edition, Gulanick/Myers pg. 566)
PLANNING
The client has established
method of communication in
which needs can be expressed
as evidenced by :

“Salamat” as verbalized by
the client.

Established eye contat while


communicating with others

Used paper and pen to


express needs
DRUG STUDY
NAME OF DRUG CLASSIFICATION INDICATION ADVERSE
REACTION
Generic Name: Anti-ulcer Drugs >Heartburn CNS: headache
Ranitidine
Hydrochloride >Erosive
>Competitively
inhibits action of esophagitis EENT: blurred
Brand Name:
histamine on the H2 vision
Zantac
at receptor sites of
Dose: parietal cells,
decreasing gastric Others: itching at
50 mg
acid secretion. injection site
Route:
IV

Frequency:
Q8
Form:
Solution
CONTRAINDICATION NURSING MONITORING
RESPONSIBILITIES PARAMETERS
>Contraindicated in >Assess patient for >May increase creatinine
patients hypersensitive to abdominal pain. Note and ALT levels.
drug and those with acute presence of blood in
porphyria. emesis, stool or >May cause false-
gastric aspirate. positive results in urine
>Use cautiously in protein test using
patients with hepatic >Drug may be added Multistix.
dysfunction. Adjust to total parenteral
dosage in patients with solutions. NORMAL VALUES:
renal function. Creatinine= 53.1-115.0
umol/L

ALT= 5-28 u/L


NAME OF DRUG CLASSIFICATION INDICATION ADVERSE
REACTION
Generic Name: Bronchodilator >To prevent CNS: dizziness,
Salbutamol exercise – weakness
Sulfate >Relaxes induced
bronchial brochospasm. CV:
Brand Name: muscles by Tachycardia,
Ventolin acting on beta – >To prevent or
adrenergic treat GI: nausea,
Dose: receptors. bronchospasm in vomiting.
1 nebule patients with
reversible RESPIRATIORY:
Route: obstructive bronchospasm
Inhalation airway disease.

Frequency:
q12

Form:
Liquid
CONTRAINDICATION NURSING RESPONSIBILITIES MONITORING
PARAMETERS
>Contraindicated in >Obtain baseline assessment of >May decrease in
patients hypersensitive patient’s respiratory status, and potassium level.
to drug or its assess patient often during K=3.5 – 5 mol/L
components. therapy.
>Evaluate the client’s respiratory
>Use cautiously in status and V/S.
patient with CV >Be alert for adverse reactions and
disorders. drug interactions.
>Teach the mother the correct use
of inhalation devices.
>Advise the mother not to use
more doses that ordered.
>Oral care after nebulization.
NAME OF CLASSIFICATION INDICATION ADVERSE
DRUG REACTION
Generic Name: Diuretics >Oliguria CNS: dizziness,
Mannitol
>Increase osmotic headache
Brand Name: pressure of >To reduce
Osmitrol
glomerular filtrate intracranial CV: hypertension
Dose: inhibiting tubular pressure
75 ml
reabsorption of h2o EENT: blurred
Route: & electrolytes; drug vision
IV
elevates plasma
Frequency: osmolality, GI: thirst
Q8 increasing h2o flow

Form: into extra cellular Skin: local pain


Liquid fluid Others: chills
CONTRAINDICATION NURSING MONITORING
RESPONSIBILITIES PARAMETERS
>Contraindicated in >Monitor v/s, including >May ↑ or ↓ electrolyte
patients hypersensitive central nervous levels.
to drug. pressure and fluid
intake & output hourly. >May interfere with test
>Contraindicated in Report increasing for inorganic
patients with anuria; oliguria. Check weight, phosphorus / ethylene
severe pulmonary renal function, fluid glycol level.
edema; active balance and serum and
intracranial bleeding; urine Na & k levels Na= 135-145 mol/L
severe dehydration. daily. K= 3.5-5 mol/L
NAME OF DRUG CLASSIFICATION INDICATION ADVERSE
REACTION
Generic Name: Antilipemics >To reduce risk of CNS: headache
Simvastatin
death from CV

Brand Name: >Inhibits HMG – disease. GI: Abdominal


Zocor CoA reductase, pain, nausea,
an early step in vomitting
Dose:
40 mg/tab cholesterol
biosynthesis
Route:
Per orem
Frequency:
OD HS

Form:
Tablet
CONTRAINDICATION NURSING MONITORING
RESPONSIBILITIES PARAMETERS
>Contraindicated in patients >Use only drug only after diet >May ↑ ALT,
hypersensitive to drug and those and other non drug therapies AST and CK
with active liver disease / prove ineffective. Patients levels.
conditions that cause should follow a standard low –
unexplained persistent elevation cholesterol diet during
of transaminase levels. therapy. ALT= 5-83 u/L
AST= 15-30
>Contraindicated in pregnant >40mg daily significantly u/L
and breast feeding women in reduces risk of death from
women of child bearing age. coronary heart disease, non
fatal MI, stroke and
>Use cautiously in patient who revascularization
has history of liver disease. procedure.
NAME OF CLASSIFICATION INDICATION ADVERSE
DRUG REACTION
Generic Name: Non – opioid analgesics >Mild pain Skin: rash
Aspirin
>To prevent GI: GI

Brand Name: >Though to reduce analgesics thrombosis bleeding,


ASA by inhibiting prostaglandin & >To reduce risk nausea
other substances that sensitive
of MI in
Dose: pain receptors. Drug may
80 mg/tab patients with
relieve pain by acting on the
previous MI
hypothalamic heat. Regulating
Route:z >Acute
Per orem center & may exert its anti-
inflammatory effect rheumatic fever
Frequency: by prostaglandin & other
OD after lunch substances

Form:
Tablet
CONTRAINDICATION NURSING MONITORING
RESPONSIBILITIES PARAMETERS
>Contraindicated in >For inflammatory >May ↓ platelet and WBC
patients hypersensitive to conditions, rheumatic count.
drug and those with fever & thrombosis give
NSAID induced sensitivity aspirin on a schedule >May ↑ liver function test
reactions, G6PD or rather than as needed. values.
bleeding disorders.
>For patients with >May falsely ↑ protein-
>Use cautiously in swallowing difficulties, bound iodine level.
patients with GI bleeding, crush non enteric-coated
impaired renal function, aspirin and dissolve in soft Platelet= 150,000 –
hypothrombinemia, vit. K food/liquid. 450,000 cubic mm
deficiency, WBC= 4,500 – 11,000
thrombocytopenia cubic mm
Prognosis
Mrs. X was admitted last January 17, 2009 at 5:40 pm at
Batangas Regional Hospital with a chief complaint of left sided
body weakness.
Several laboratory examinations were done to her which
includes hematology, blood chemistry, urinalysis and chest x –
ray.
After 4 days of therapeutic management, the prognosis
for recovery is fair although Mrs. X’s blood pressure subsided to
130/90 mmHg. There was also a decrease evidence of
respiratory distress hence discharge planning was possible. He
responded to it positively that medicates the improvement with
Mrs. X’s status. She was advised to seek to seek consultation
after a week. She is still subjected to series of examinations for
continuous monitoring of her condition.
She was discharged on a wheelchair last January 21,
2009 at 4:45pm.
DISCHARGE PLANNING

Subjective:
“Pwede na raw kaming umuwi sabi ng Doktor”.

Objective:
-Stable vital signs:
BP - 130/90 mmHg
Temperature - 36.8oC
Respiratory rate - 18 breaths per minute
Pulse rate - 88 beats per minute
-Can move her left upper and lower extremities in minimal range

Assessment:
May go home as per Doctor’s order.

Planning:
After 1 hour of nursing interventions, the client will be able to
enumerate ways on how to provide adequate care.
Implementation:
Conducted health teaching to the mother as follows:

MEDICATONS:
> Instructed the client to take the home medications as
prescribed by the doctor upon discharge:

Citicholine 500 mg/cap 1 capsule three times a day ;


Simvastatin 40 mg/cap 1 capsule once a day ;
Amlodipine 10 mg/tab 1 tablet once a day ;
Captopril 25 mg/tab 1 tablet sublingual prn BP160/90 mmHg;
Co – amoxiclav 625 mg/cap 1 capsule twice a day for seven
days ;
Acetylcystiene 200 mg/sachet 1 sachet three times for 5 days;
ASA 80 mg/tab 1 tablet once a day after lunch ; and
Losartan 50 mg/tab 1 tablet once a day
ENVIRONMENT AND EXERCISE:
> Advised patient and relatives to provide a clean and allergen –
free environment conducive for patient’s recovery.
> Advised the relatives to provide a quiet and calm environment.
> Emphasized the importance of stress and injury free
environment to prevent trauma and any other complication.
>Instructed the client to have adequate rest and sleep.

TREATMENT:
> Informed the patient regarding the importance of her
compliance to medication as part of his treatment regimen.
> Advised the relatives that the head of the bed must be
elevated at 300.
> Encouraged client to increased activity if tolerated.
> Advised the relatives to initiate therapy prevent further
complications.
> Discussed with the client the relaxation techniques to combat
stress.
HYGIENE:
> Encouraged client to promote proper oral hygiene to
prevent any complication.
> Instructed the client to perform self care activities such
as bathing and dressing if tolerated.

OPD:
> Informed the client and relatives that further monitoring
will be conducted and so the need for regular check – up
is highly recommended. To come back at the hospital
after 1 week.

DIET:
> Advised the client to eat a variety of foods, those with
moderate amount of salt and sodium.
> Advised the client to avoid high cholesterol foods.
> Advised the client to have adequate caloric intake.
SPIRITUALITY:

> Advised the client to seek God’s help for the


recovery and give improvement of the patient’s
health and never forget to ask guidance and
support from our Lord.

Evaluation:

The client was able to enumerate ways on how to


provide adequate care.
ACKNOWLEDGEMENT
Despite all the trials and challenges, there came the final
conquest. Words alone cannot describe those who had contributed in
one way or another towards the completion of this case study.

We lift up our glorious praises and endless thanks to the


Almighty God for continually blessing us while the preparation of this
case study and for giving us the strength to overcome trials and for
every little thing he’d done for us. Likewise, we extend our sincere
gratitude and deepest appreciation to the following people who
unselfishly shared their expertise, invaluable assistance and
inspiration for the realization of this case study.
To our dear parents, for assisting us in our needs, financially and
emotionally; for being there whenever we need them, for staying on our
side through ups and downs and most of all for making us a responsible
individual.

To our Clinical Instructor, Ms. Sharon P. Remolana, for sharing her


knowledge to the best of her ability; for guiding us the right way, we will
treasure all the learnings that she had taught us.

To the patient, Mrs. X, for allowing us to make the study of her


condition.. Mrs. X, who is suffering from deprivation of health and are ailing,
they are the reasons why this study was conducted, though no bad intents
of continued agony is felt.
To the staff of the IMC, especially Ma’am Rose, for letting us
lend books and assisting us in all our needs without hesitations.

To the different theorists and authors that influenced the


large arena of patient care, differentiating nursing among other
profession in dealing with its clientele. Their works served as basis
of this study.

To our classmate. Miss Karen Michelle B. Lecaroz, for


lending some time editing our case study and helping us to finish it.

To our friends and to all the important person in our lives.


For suggestions they gave for the enrichment of this work.
bibliography
Applying Nursing Process, Alfaro- Le Fevre Rosalinda, pg. 207
Current Diagnosis and treatment,Marcus A.Krupp and Milton J. Chatton
Delmar’s Manual of Laboratory and Diagnostic Test, Rick Daniels
Delmar’s Pediatric Nursing Care Plans, 3rd edition,Luxner
Health Assesment & Physical Examination, Estes
Health Assesment in Nursing 3rd edition, Janet Weber & Jane Kelley
Human Anatomy and Physiology, Hole,Jr,et.al, 6th edition
Laboratory and diagnostic tests with nursing implications Seventh Edition,Joyce
Lefever Kee
Laboratory Tests and Diagnostic Procedures 5th Edition, Chernecky
Medical-Surgical Nursing, Brunner and Suddharts, Smeltzer,vol.1 & 2
Medical-Surgical Nursing Pathophysiological Concept, pge 496
Medical-Surgical, 6th edition, Burner et al, pg 468-469
Medical-surgical nursing, Smeltzer,et al.
Medical- Surgical Nursing Critical Thinking for collaborative care, vol.15th edition,
Ignatius, et.al. pg. 633-639
Medical Surgical for Nursing 7th edition Lewis et.al.
MIMS 107th edition 2006
Nurses’ Pocket Guide 11th edition, by Donges et. Al.
Nursing Care Plan,7th edition, Doenges, et.al
Nursing Care Plans; 6th edition, Donenges et. Al, pg. 130.
Nursing Care Plan, Meg Gulanck,et. Al, pg. 3
Nursing Care Plan 6th edition Gulanick/Myers
Pediatric Nursing Care Plan, Axton, et. Al, pg. 296-300
Portable Diagnostic Tests, Lippincott
www.emedicine.com
www.medscape.com