Cerebrovascular Accident

Case Presentation

I. INTRODUCTION

The world as a whole has been facing different constant changes not only in the environment but also in people¶s lives. As changes occur, the more people become in need to adopt with these changes, thus, and we expose ourselves to illness that could even lead to unwanted events in our lives. Our nursing case presentation is about Cerebrovascular Accident discussing Ischemic stroke. The content includes the patient¶s general data and physical assessment, anatomy, physiology and pathophysiology, review of related literature, laboratory and pharmacology.

The highlight if the presentation deals with the nursing care presentation deals with the nursing care plan of our patient revolving on his priority nursing problems, goals of care, appropriate nursing intervention and its feedback evaluation. Our group is composed of 11 Nursing students. We have chosen this case as a help for studies and eliminating and prevention in the enlarging occurrence of Cerebrovascular diseases like this. We greatly acknowledge the cooperation extended by the patient. We also appreciate the effort of Our Lady of Fatima University Medical Center staff and the guidance provided to us by our Clinical Instructor, Mrs. Morales, and most importantly we thank our God Almighty for all the graces he bestowed on us.

GENERAL DATA Name: Remedios.II. Valenzuela City Date of Admission: December 6 2010 Date of Discharge: December 10 2010 Admitting Diagnosis: Cerebrovascular Accident . Salazar Estrellia Age: 54 Civil Status: M Date of Birth: October 25 1956 Place of Birth: Valenzuela City Nationality: Filipino Religion: Roman Catholic Address: 618 Caloong I.

. above symptoms have persisted which prompted patient to seek consult of his physician¶s clinic. associated with nape pain and dizziness. hence the subsequent admission. There was also a noted limitation of motion of the neck area. Patient was advised to be admitted for further evaluation and management. No medications taken and no consult were done. blurring of vision and loss of consciousness. Few hours prior to admission. There was no associated vomiting. patient complained of headache.Chief Complaint: HEADACHE ‡ History of Present Illness: One day prior to admission.

no colds. no palpitations >No pain urination >No diarrhea Past Medical History: (+) HPN.DX 2002 -on maintenance medication (-) DM (-) Asthma (+) Previous hospitalization 2007 FUMC (+) CVO Bleed ±CVD bleed vs. slight difficult of breathing >No chest pain. infarct .Review of Systems: >No yellowish discoloration of the skin and sclera >No cough.

Personal/ Social History: (-) Smoker (-) Alcoholic drinker Family History: (+) HPN on both sides (+) DM on mother side (+) CA both sides -Cervical CA. Breast CA .

. General Survey: Vital Signs: Musculoskeletal disorder BP: 100/90 R/to CVD re-intant PR: 81 S/p CVD infarct RR: 18 Left with sensory deficit Temp: 36. coherent.PHYSICAL ASSESSMENT Done on Admission: December 6 2010 General Assessment: Conscious. ambulatory. NICRD.8 Right extremely.III.

Skin: Warm. with good skin turgor and skin texture. moist HEENT: ‡ PPC. ‡ (-) CLAD ‡ (-) TPC Neck: (+) Limitation of the RAM of neck . AS.

soft ‡ (-) tenderness Extremities: The client cannot resist force when asked to resist specially the left arm. nabs. ‡ (-) Retractor CBS Abdomen: ‡ Flabby. Muscle strength is 3/5 on the right and 2/5 on the left. The IV site is in her left arm. Lymph nodes are not palpable. The peripheral pulses are equal. .Chest: ‡ SCE.

Anatomy of the Brain . ANATOMY AND PHYSIOLOGY A.IV.

Inside the cranium. along with the bones of the face.The cranium The brain is protected by a bony covering called the cranium (which. makes up the skull). The meninges are made up of 3 layers of tissue: ‡ Pia mater ± the layer closest to the surface of the brain ‡ Arachnoid membrane ± the middle layer of tissue ‡ Dura mater ± the outer-most layer . the brain is surrounded by the meninges.

The cerebrum is responsible for: ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ Movement Body temperature Touch Vision Hearing Judgment Reasoning Problem solving Emotions Learning .The cerebrum ± the front of the brain The largest part of the brain located in the front is called the cerebrum.

The right side is involved with creativity and artistic abilities. . and the left cerebral hemisphere controls the right. the right cerebral hemisphere controls the left side of the body. In general.The cerebrum has 2 parts: the right cerebral hemisphere and the left cerebral hemisphere. They are connected at the bottom and have a deep groove running between them. The left side is important for logic and rational thinking.

speech.The hemispheres of the cerebrum are divided into lobes. language and speech functions ‡ Parietal lobes are involved with sensation ‡ Occipital lobes are the primary vision centers . and motor development ‡ Temporal lobes are responsible for memory. or broad regions of the brain. Each lobe is responsible for a variety of bodily functions: ‡ Frontal lobes are involved with personality.

The inner part is called white matter and contains connections of nerves. . The outer part of the cerebrum is called gray matter and contains nerve cells.The surface of the cerebrum appears wrinkled and is made up of deep grooves (called sulci) and bumps or folds (called gyri).

and the medulla oblongata. the cerebellum. including: Breathing Consciousness Cardiac function Involuntary muscle movements Swallowing Movement of the eyes and mouth Relaying sensory messages (pain. The brainstem has three main parts. the midbrain. and the spinal cord are all connected to the brainstem. etc. the pons. heat. noise. The brainstem is like the hard-drive of a computer.The brainstem ± the middle of the brain The brainstem is located in front of the cerebellum.) Hunger . The cerebrum. ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ The brainstem controls vital functions of the body. It is the main control panel for the body that passes messages back and forth between the brain and other parts of the body.

responsible for: ‡ ‡ ‡ ‡ Voluntary muscle movements Fine motor skills Maintaining balance. . and the right cerebellum controls the right side of the body. the cerebellum contains more nerve cells than both hemispheres combined. posture.´ However.The cerebellum ± the back of the brain Behind the cerebrum at the back of the head is the cerebellum. cerebellum means ³little brain. the left cerebellum controls the left side of the body. In Latin. and equilibrium Unlike the cerebrum. The cerebellum is primarily a movement control center.

2. The Motor. . Sensory and Association Areas of the Cerebral Cortex.Figure 4.

The ventricles are important in providing nourishment to the brain. There are fluidfilled cavities within the brain called ventricles. The ventricular system produces and processes cerebrospinal fluid ± a clear. . watery substance that flows around the brain and helps cushion and protect it. The brain is not a solid organ.Other important parts of the brain Ventricular system.

facial expressions ‡ Vestibulocochlear ± hearing. balance ‡ Glossopharyngeal ± taste. chewing ‡ Abducens ± eye movements ‡ Facial ± taste. The brain also contains 12 pairs of cranial nerves each responsible for specific functions in the body: ‡ Olfactory nerve ± smell ‡ Optic nerve ± vision ‡ Oculomotor ± eye movements. taste ‡ Accessory ± neck and shoulder muscles ‡ Hypoglossal ± tongue movement . swallowing ‡ Vagus ± swallowing. eyelid opening ‡ Trochlear ± eye movements ‡ Trigeminal ± facial sensations.Cranial nerves.

The pituitary gland is located in the center of the brain and is about the size of a dime.Pituitary gland. as well as the hormones responsible for normal growth and sexual maturation.´ is responsible for a number of functions including producing hormones for the thyroid and adrenal glands. . often referred to as the ³master gland. The pituitary gland.

. which may result in irreversible tissue damage when blood flow is occluded for even short periods of time. or 750 ml per minute. the brain lacks additional collateral blood flow. The brain¶s blood pathway is unique because it flows against gravity. its arteries fill from below and the veins drain from above. The brain does not store nutrients and has a high metabolic demand that requires the high blood flow. In contrast to other organs that may tolerate decrease in blood flow because of their adequate collateral circulation. Cerebral Circulation The cerebral circulation receives approximately 15% of the cardiac output.B.

Two internal carotid arteries and vertebral arteries and their extensive system of branches provide the blood supply to the brain. enters the cranium through the foramen magnum. the basilar artery divides to form the two branches of the posterior cerebral arteries. flow back to and upward on either side of the cervical vertebrae.Arteries. The vertebral arteries join to become the basilar artery at the level of the brain stem. . The vertebrobasilar arteries supply most of the posterior circulation of the brain. The internal carotids arise from the bifurcation of the common carotid and supply much of the anterior circulation of the brain. The vertebral arteries branch from the subclavian arteries.

Functionally.At the base of the brain surrounding the pituitary gland. and anterior and middle cerebral arteries. This ring is called the circle of Willis and is formed from the branches of the internal carotid artery. The arteries of the circle of Willis can provide collateral circulation if one or more of the four vessels supplying to become occluded or are ligated. . a ring of arteries is formed between the vertebral and internal carotid artery chains. and anterior and anterior and posterior communicating arteries. the posterior portion of the circulation and the anterior or carotid circulation usually remain separate.

The arterial anastomoses along the circle of Willis are frequent sites of aneurysms. Aneurysms may be congenital or the result of degenerative changes in the vessel wall associated with atherosclerotic vascular disease. the neurons distal to the occlusion are deprived f their blood supply and the cells die quickly. The result is hemorrhagic stroke (cerebrovascular accident or infarction). or a thrombus. Theses can be formed when the pressure at a weakened arterial wall causes the artery to balloon out. If an artery with an aneurysm bursts or becomes occluded by vasospasm. The effects of the occlusion depend on which vessels are involved and which areas of the brain these vessels supply. . an embolus.

returning the blood to the heart. .Veins. The veins reach the brain¶s surface. then cross the subarachnoid space and empty into the dural sinuses. which are vascular channels lying within the tough Dura mater. Cerebral veins and sinuses are unique because. join larger veins. unlike other veins in the body. they do not have valves to prevent blood from flowing backward and depend on both gravity and blood pressure. Venous drainage for the brain does not follow the arterial circulation as in other body structures. The network of sinuses carries venous outflow from the brain and empties into the internal jugular vein.

as viewed from ventral surface.Figure 4.3. The Arterial Blood Supply of the Brain. including the Circle of Willis. .

A person's risk of dying if he or she does have a stroke also increases with age. but causes of these disparities have not been explained.V. Geographic disparities in stroke incidence have been observed. 95% of strokes occur in people age 45 and older. stroke can occur at any age. Advanced age is one of the most significant stroke risk factors. . and etiology varies by age. and two-thirds of strokes occur in those over the age of 65. Incidence Stroke could soon be the most common cause of death worldwide. The incidence of stroke increases exponentially from 30 years of age. including the existence of a "stroke belt" in the southeastern United States. and causes 10% of deaths worldwide. However. REVIEW OF RELATED LITERATURE A. including in childhood. ranking after heart disease and before cancer. Stroke is currently the second leading cause of death in the Western world.

they are older on average when they have their strokes and thus more often killed (NIMH 2002). Since women live longer. Having had a stroke in the past greatly increases one's risk of future strokes.Family members may have a genetic tendency for stroke or share a lifestyle that contributes to stroke. Primary among these are pregnancy. childbirth. Some risk factors for stroke apply only to women. Higher levels of Von Willebrand factor are more common amongst people who have had ischemic stroke for the first time. Men are 25% more likely to suffer strokes than women. yet 60% of deaths from stroke occur in women. . menopause and the treatment thereof (HRT). The results of this study found that the only significant genetic factor was the person's blood type.

or loss of balance or coordination. Clinical Presentation and Medical Management An ischemic stroke can cause a wide variety of neurologic deficits. The patient may present with any of the following signs and symptoms: -Numbness or weakness of the face. the size of the area of inadequate perfusion. -Visual disturbances. and the amount of collateral (secondary or accessory) blood flow. arm. -Trouble speaking or understand speech. -Confusion or change in mental status.B. depending on the location of the lesion (which vessels are obstructed). cognitive and other functions may be disrupted. dizziness. especially on ne side of the body. . cranial nerve. or leg. -Sudden severe headache -Motor sensory. -Difficulty walking.

Table 5-1. -Approach the patient from side of the intact field of vision -Instruct/remind the patient to turn the head in the direction of visual loss to compensate for loss of visual field -Encourage the use of eye glasses if available -when teaching the patient. -Difficulty judging distances. Neurologic Deficits of Stroke: Manifestations and Nursing Implications Neurologic Deficit Manifestation Nursing Implication/ Patient Teaching Application Visual field deficits Homonymous hemianopsia (loss of half of the visual field) -Unaware of the persons or objects on side of the visual loss. do so within the patient s intact visual field. -Place objects within intact field of vision. -Neglect of one side of the body. .

-Consistently place patient care items in the same location.Loss o peripheral vision >Difficulty seeing at night >Unaware of objects or the borders of objects -Avoid night driving or other risky activities in the darkness -Place objects in center of patient¶s intact visual field. Diplopia >Double of vision -Explain to the patient the location of an object when placing it near the patient. -Encourage the use of a cane or other object to identify objects in the periphery of visual field. .

unsteady gait -Unable to keep feet together.Motor Deficits Hemiparesis -Weakness of the face. Instruct the patient not to walk without assistance or supporting device. -Encourage the patient to provide range-of-motion exercises to the affected site. and leg on the same side (due to a lesion in the opposite hemisphere) Ataxia -Staggering. -Provide immobilization as needed on the affected site. arm. cane). Hemiplegia -Paralysis of the face. needs a broad base to stand -Support patient during the initial ambulation phase -Provide supportive device for ambulation (walker. -exercise unaffected limb to increase mobility. and leg on the same side (due to a lesion in the opposite hemisphere) -Place objects within the patient s reach on the non affected site. arm. _-Maintain body alignment in functional position. . strength and use.

-Allow ample time to . Dysphagia Difficulty swallowing -Test the patient s pharyngeal reflexes before offering food or fluids. -Place food on the affected site of the mouth. -Assist the patient with meals. -Allow the patient sufficient time to respond to verbal communication. -Support patient and family to alleviate frustration relate to difficulty communicating.Dysarthria -Difficulty in forming words -Provide the patient with alternative methods of communicating.

Verbal deficits Expressive aphasia Unable to form words -Encourage patient to that are understandable. -Provide range of motion to affected areas and apply corrective devices as needed.Sensory deficit Paresthesia (occurs on the site opposite to the lesion) Numbness and tingling of extremity Difficulty with proprioception -Instruct the patient to avoid using this extremity as the dominant limb due to altered sensation. repeat sounds of the may be able to speak in alphabet. . can speak but may not make sense. single word responses Receptive aphasia Unable to comprehend the spoken word. -Speak slowly and clearly to assist the patient in forming sounds.

Global (mixed) aphasia Combination of both receptive and expressive aphasia

-Speak clearly and in simple sentences; use gestures or pictures when able. -Establish alternative means of communication.
-Reorient patient to

Cognitive Deficits

-Short and long term memory loss -Decreased attention span -Impaired ability to concentrate -Poor abstract reasoning Altered judgment

time, place and situation frequently. -Use verbal and auditory cues to orient patient. Provide familiar objects ( family photographs, favorite objects) -Use no complicated language. -Match visual tasks with a verbal cue; holding a toothbrush, stimulate brushing of teeth while saying, I would like you to brush your teeth now.) -Minimize distracting noises and views when teaching the patient. -Repeat and reinforce instructions frequently.

Emotional Deficits -Loss of self control -Emotional lability -Decreased tolerance to stressful situations -Depression Withdrawal -Fear, hostility, and anger Feelings of isolation -Support patient during uncontrollable outbursts. -Discuss with the patient and family that the outbursts are due to the disease process. -Encourage the patient to participate in group activity. -Provide stimulation for the patient. -Control stressful situations, if possible. -Provide a safe environment. -Encourage patient to express feelings and frustrations related to disease process.

C. Laboratory and Radiologic Examination
Any patient with neurologic deficits needs a careful history and a complete physical and neurologic examination. Initial assessment will focus on airway patency, which may be compromised by loss of gag or cough reflexes and altered respiratory pattern; cardiovascular status (including blood pressure, cardiac rhythm and rate, carotid bruit), and gross neurologic losses. Stroke patients may present to the acute care facility at any point along a continuum of neurologic involvement. A system that uses the time course to classify patients along this continuum may be used to guide treatment. Strokes use the time course is commonly classified in the following manner: (1) transient ischemic attack; (2) reversible ischemic neurologic disease; (3) stroke in involution; and (4) compensated stroke. The initial diagnostic test for a stroke is a non contrast computed therapy (CT) scan performed emergently to determine of the event is ischemic or hemorrhagic (which determines treatment). Further diagnostic work up for ischemic stroke involves attempting to identify the source of thrombi or emboli. A 12-lead electrocardiogram and a carotid ultrasound are standard tests. Other studies may include Cerebral Angiography, transcranial flow studies, transthoracic or transesophagel echocardiography, magnetic resonance imaging of the brain and/or neck, xenon CT, and single photon emission CT. Remarkable advances in technology now make it possible to examine how the brain looks, works and gets its blood supply. These tests can outline the affected part of the brain and help define the problem created by stroke. Most of these tests are safe, painless and can be done as an outpatient. However, in many cases these tests are ordered when a patient is hospitalized with a stroke. A doctor must decide on a caseby-case basis whether such tests will be useful, and if so, which ones to use. The following tests are described in this section:

Evoked response test vii. Digital subtraction angiography (DSA) iv. Electroencephalogram (EEG) vi. Carotid phonoangiography Computerized axial tomographic scan (CT or CAT scan) iii. Radionuclide angiography . ii. Doppler ultrasound test v.i. Magnetic resonance imaging scanning (MRI) viii.

What imaging tests are done on the brain? ‡ Computerized axial tomographic scan (CT or CAT scan) ² Uses X-rays to generate an image of the brain. Hemorrhagic strokes result from a ruptured blood vessel in the brain causing bleeding into brain tissue. (Ischemic strokes are caused by a clot that blocks an artery. what kind. Doctors use CT to determine whether a stroke has occurred and. if so. The test causes no discomfort.) CT scanning takes from 5 to 10 minutes to complete (mostly less than 5 minutes). .

which are potential sources for hemorrhagic stroke. This scanner has a magnetic field in which the head is subjected to bursts of energy of a known magnetic frequency. This test is performed in 40 minutes to one hour.‡ Magnetic resonance imaging scanning (MRI) ² The stroke patient is placed into the MRI scanner. and causes no discomfort. The response of the brain cells to these bursts of energy is detected as signals that ultimately generate an image of the brain. location and size of aneurysms and arteriovenous malformations. These are used to determine the presence. MRI can give very accurate images of the brain. .

. the bloodstream then carries them toward the head.‡ Radionuclide angiography ² Radioactive compounds are injected into a vein in the arm. As the radioactive compound circulates in the bloodstream. This imaging procedure can show areas where the brain has been deprived of blood flow and is damaged. Once the radioactive compound reaches the brain. it constantly emits bursts of radiation. these bursts of radiation are detected and used to form an image of the brain.

and this test will help doctors determine if seizures are present and if treatment with medications is needed. . Some people who have strokes are prone to seizures. The electrodes can detect the electrical activity in the form of impulses that are then transcribed to paper. frequency (how often impulses occur during a given time) and location (what region of the brain produces these impulses).What tests show the brain's electrical activity? ‡ Electroencephalogram (EEG) ² Small metal disks (electrodes) are placed at strategic locations on a person's scalp. duration (the width of the impulse). an EEG can provide valuable information about underlying problems in the brain. By observing such impulse characteristics as intensity (the size of the impulse).

one of the nerves in an arm or leg is electrically stimulated. The responses from these sensory stimuli can indicate abnormal areas of the brain. For bodily evoked responses.‡ Evoked response test ² a diagnostic procedure that provides a measurement of the brain's ability to process and react to different sensory stimuli. A doctor evokes a visual response by flashing a light or checkerboard pattern in front of a patient. . For auditory evoked responses. a doctor produces a sound in one of the patient's ears.

The change in frequency of the sound waves relates to the speed of the blood cells and thus the blood flow. . A Doppler probe or instrument capable of generating ultrasound waves is placed on the neck very near to the carotid artery. is then detected by the same probe. This test takes an hour or more. now returning to the probe at a different frequency. The reflected sound wave. and causes no discomfort.What tests show blood flow? ‡ Doppler ultrasound test ² Uses highfrequency sound waves to detect blockages in the carotid artery. Ultrasound waves from the probe travel through the neck and bounce off the moving blood cells.

causes the blood flow to become turbulent. The presence of a bruit may indicate a blockage in the carotid artery and is cause for more tests. very close to the carotid artery. blood flows in a smooth and controlled manner. called a bruit (BROO'e). . the presence of blockages. However. which can be detected and registered by the microphone. This turbulent blood flow can create a sound. to record sounds. Ordinarily.‡ Carotid phonoangiography ² a sensitive microphone is placed on the neck. such as those caused by atherosclerosis. in a normal artery.

Some people may feel a warm sensation as the contrast medium is injected into the blood vessels. . an X-ray machine quickly takes a series of pictures of the head and neck. A contrast dye is injected through the catheter and allowed to circulate in the bloodstream. A thin plastic tube (a catheter) is inserted into a major artery of the leg and advanced through the body's major vessels until it reaches the brain's blood vessels. The images track the movement of the contrast dye as it moves through the brain's blood vessels. This imaging technique lets the doctor identify and localize the source of a blocked blood vessel that caused the stroke. At that point.‡ Digital subtraction angiography (DSA) ² gives an image of the brain's major blood vessels.

Digital subtraction angiography is used to define carotid artery obstruction and provides information on patterns of cerebral blood flow. There are diminished or absent of carotid pulsationsin the neck. direct visualization. and photographic recording of carotid bruits. Carotid angiography allows visualization of intracranial and cervical vessels. . this involves auscultation. a bruit (abnormal sound heard on auscultation resulting from interference with normal blood flow) may be heard over the carotid artery.In patient with TIA. Oculoplethysmography measures the pulsation of blood flow through the ophthalmic artery. Diagnostic tests for TIA may include carotid phonoangiography.

but its main use in clinical medicine is during the assessment of whether or not the degree of disability caused by a given stroke merits treatment with tPA. . sensation. A certain number of points are given for each impairment uncovered during a focused neurological examination.D. movement. where it allows for the objective comparison of efficacy across different stroke treatments and rehabilitation interventions. A maximal score of 42 represents the most severe and devastating stroke. Current guidelines as of 2008 allow strokes with scores greater than 4 points to be treated with tPA. including consciousness.NIH Stroke Scale The National Institute of Health (NIH) stroke scale (NIHSS) is a standardized method used by physicians and other health care professionals to measure the level of impairment caused by a stroke. speech. vision. and language. The NIH stroke scale serves several purposes. Another important use of the NIHSS is in research. The NIH stroke scale measures several aspects of brain function.

the release of more calcium and glutamate. at this point. This disruption in blood flow initiates a complex series of cellular metabolic events referred to as the ischemic cascade. and the influx of calcium can be limited with the use of cacium channel blocker. an area of low cerebral blood flow. which generates large amounts of lactic acid. and the generation of free radicals. These processes enlarge the area of infarction into the penumbra. causing a change in pH level. The influx of calcium and release of glutamate. . extending the stroke. exists around the area of infarction. if continued. Early in the cascade. The penumbra area can be revitalized with the administration of tissue plaminogen activator (t-PA). The ischemic cascade threatens cells in the penumbra because membrane depolarization of the cell walls leads to an increase in intracellar calcium and the release of glutamate.VI. The mitochondria must then switch to anaerobic respiration. Thus membrane pumps that maintain electrolyte balances begin to fail and the cells cease to function. The ischemic cascade begins when cerebral blood flow falls less than 25 ml/100 g/min. there is disruption of the cerebral blood flow due to obstruction of blood vessel. referred to as penumbra region. This switch to the less efficient anaerobic respiration also renders the neuron incapable of producing sufficient quantities of adenosine triphosphate (ATP) to fuel the depolarization process. neurons can no longer maintain anaerobic respiration. activate a number of damaging pathways that result in the destruction of the cell membrane. The penumbra region is ischemic brain tissue that can be salvaged with timely intervention. vasoconstriction.PATHOPHYSIOLOGY In an ischemic brain attack.

Colorado .Ischemia Energy failure Acidosis Ion imbalance Increase Glutamate Depolarization Intracellular calcium increased Cell injury and death Figure 6-1. Englewood. Process contributing to ischemic brain iinjury. Pathophysiology of the Cerebrovacular Accident. Courtesy of National Stroke Association.

0-10.01 0.60 Normal Normal Normal Normal Higher .01-0.VII.02-0.42 % 5.40 0.37-0.9 Normal values 123-152 g/ L 0.36 11. COMPLETE BLOOD COUNT Dec 06 2010 Hemoglobin Hematocrit WBC count Differential Count Lymphocytes Monocytes Eosinophils Basophils Neutrophils 117 g/L 0.07 0.03 0-0.69 0.02 0.40-0. LABORATORY RESULTS A.08 0.01 0.20-0.22 0.0 x 10 g/L Interpretation Lower Slightly lower Higher 0.

7-22.RBC MCV MCH MCHC RDW Platelet MPV PDW CT BT Reticular Count ESR 4.5-7.17-39.5% 0-20 mm/hr Normal Lower Lower Lower Normal Normal Higher .5 321 14.5x10/2 L 88-96 27-33 pg 330-360 g/L 12.5 3.47 4. 05-1.1 2-4 mins.7 % 150-450x 10 g/L 4.5-5. 1-3 mins.3 210 9.98 73 23.

B.32 mmol/L 1.3 mmol/L 1.66 mmol/L .0 mmol/L 0.Clinical Chemistry 88.12 mmol/L 92 mmol/L Cholesterol Triglycerides Didevet HDL Cholesterol LDL Cholesterol 5.2mmol/L 135 mmol/L 4.9 mmol/L 3. Electrolytes Creatinine Sodium Potassium Calcium Chloride C.

. -Visualized soft tissue planes within normal. -There is no evidence of canal stenosis -Osteophytic formation is ruled at C5 and C6 vertebral bodies. December 7 2010 Findings: -Scannogram shows mild reversal of the cervical lordesis most likely due to muscular spasm. -Thecal sac is intact. CT Scan: Cervical Spine with settings for the soft tissues and bone detail revealed.CT Scan December 7 2010: Impression: Cortical cerebral atrophy. -No other findings noted.

Mannitol Brand name Patient¶s Dosage Classification Indication Osmitrol 75 mg prn Diagnostic agent.PHARMACOLOGY A.VIII. urinary irrigant y Prevention and treatment of oliguric phase of renal disease y Reduction of intracranial pressure and treatment of cerebral edema. of elevated IOP when the pressure cannot be lowered by other means y Promotion of the urinary excretion of toxic substances y Diagnostic use: measurement of GFR y Irrigant in transurethral prostatic resection or other transurethral precedures . osmotic diuretic.

thereby hindering the reabsorption of water and leading to a loss of water. Pharmacokinetics Route IV Irrigant Onset 30-60 minutes Rapid Peak 1 hour Rapid Duration 6-8 hours Short Metabolism T 1/2 : 15-100 minutes Distribution Crosses placenta. leading to decreased swelling in posttransurethral prostatic resection. sodium. may enter breast milk Excretion Urine Dosage and Administration . chloride (used for diagnosis of glumerular filtration rate).Action Elevates the osmolarity of the glomerular filtrate. thereby reducing IOP. creates an osmotic effect. creates an osmotic gradient in the eye between plasma and oclular fluids.

draw blood at the start and at the end of the time for measurement of mannitol in mg/ml plasma. irrigate as needed. Adjunctive therapy to promote dieresis in intoxications: maximum of 200 g IV of mannitol with other fluids and electrolytes.5-2 g/kg as a 25% solution. Prevention of oliguria: 50-100 g IV as a 5% -25% solution Treatment of oliguria: 50-100 g IV of a 15%-25% solution. Reduction of IOP: infuse 1.2 g/kg IV (about 50 ml of 25% solution. collect urine with a catheter for the specified time for measurement of mannitol in mg/min.Adults: IV infusion only.5-2g/kg IV as a 15%-25% solution over 30-60 minutes. 20% solution. individualized concentration and rate of administration. Urologic irrigation: use prepared 5g/ 100ml distilled water solution. Adjust dosage to maintain urine flow of 30-50 ml/hr. Evidence of reduced pressure should be seen in 15 minutes. reevaluate patient situation. Or 15% solution over 30 minutes. Measurement of glumerular filtration rate: dilute 100 ml of a 20% solution with 108 ml of sodium chloride injection. Dosage is 50200g/day. Infuse this 280 ml of 702% solution IV at rate of 20 ml/ min. . Reduction of intracranial pressure and cerebral edema: 1. If no response to second dose. If used preoperatively. use 60-90 minutes before surgery for maximal effect. repeat dose. If urine flow does not increase. Test dose of mannitol for patients with inadequate renal function: 0. 75 ml of a 20% solution) in 3-5 minutes to produce urine flow of 30-50 ml/hour.

Adverse Reactions and Side effects Central Nervous Dizziness.Contraindications Precaution Contraindicated with anuria due to severe renal disease Use cautiously with pulmonary congestion. chest pain Urticaria. headache. active intracranial bleeding (except during crainiotomy). blurred vision. lactation. renal disease. thirst Diuresis. thromboplebitis. skin necrosis with infiltration Nausea. pregnancy. edema. dry mouth. anorexia. HF. urine retention Fluid and electrolyte imbalances Pulmonary congestion. seizzures System Cardiovascular Dermatologic Gastrointestinal Genitourinary Hematologic Respiratory Hypotension. hypertension. rhinitis . dehydration. tachycardia. heart failure.

. then cool to body tempearature before administering. If crystals are seen. GI upset (eat frequent small meals). warm the bottle in a hot water bath. muscle strength . y Report difficulty of breathing. dry mouth (suck sugarless lozenges). crystallization may occur. edema. blurred vision (use caution when moving for assistance). pulses. pain in the IV site. headache. lactation Skin color. add at least 20 mEq of sodium chloride to each liter of mannitol solution y Do not exposesolutions to low temperatures. y Make sure the infusion set contains a filter if giving concentrated mannitol. y Monitor serum electrolyte periodically with prolonged therapy. urinalysis . hydration. lesions. renal disease. orientation. pupils. perfusion. active intracranial bleeding. Respiratory pattern. Teaching Points y You may experience these side effects: Increased urination. If blood must be given. dehydration. urinary output patterns. heart failure. BP. chest pain. adventitious sounds. reflexes. renal function tests Interventions Warning: Do not give electrolyte free mannitol with blood. pregnancy.Nursing Considerations Assessment y History y Physical Pulmonary congestion. serum electrolytes.

B. Ultral ER 50 mg PO q 6h Analgesic (centrally acting) Opoid Analgesic relief of moderate to moderately severe pain y relief of moderate to severe chronic pain in adults who need RTC Treatment for extended periods (ER tablets) y Unlabelled uses: Premature ejaculation. somnolence. . causes many effects similar to opoids. restless leg syndrome y Action Binds to mu-opiod receptors and inhibits the reuptake of norepinephrine and serotonin.Tramadol hydrochloride Brand name Patient s Dosage Classification Indication Ultral. nausea. constipation .but does not have the respiratory depressant effects.dizziness.

Maximum 200 mg/day. Alternatively. After titration. .Pharmacokinetics Route Onset Peak Oral 1 hour 2 hours Metabolism Hepatic. ER tablets should not be used in patients with creatinine clearance less than 30 ml/min. titrated by 100-mg increments every 5 days. Geriatric Patients or patients with hepatic or renal impairment Older than 75 years old: do not exceed 300 mg/day Patients with cirrhosis: 50 mg every 12 hour ER tablets should not be used in severe hepatic impairment Patients with creatinine clearance less than 30ml/min: 50-100 mg PO every 12 hours. do not exceed 400 mg/day y Patients with moderate to moderately severe chronic pain: Initiate at 25 mg /day in the morning. 100-mg ER tablet once daily. Then increase every 3 days to reach 200 mg/day. t ½ : 6-7 hours Distribution Crosses placenta. do not exceed 300 mg/day. and titrate in 25-mg increments every 3 days to reach 100 mg/day. do not exceed 400 mg/day. 50-100mg every 4-6 hours. enters breast milk Excretion Urine Dosage and Administration Adults: y Patients who require rapid analgesic effect: 50-100mg PO every 4-6 hr.

pruritus. TCAs. pallor. bradycardia Sweating. MAOIs. dizziness or vertigo. Precaution Adverse Reactions and Side effects Central Nervous System Cardiovascular Dermatologic Gastrointestinal Others Sedation.Contraindications Contraindicated with allergy to tramadol. urticaria Nausea. dreaming. rash. concomitant use of CNS depressants. constipation. anaphylatoid reactions . seizures. vomiting. seizures Hypotension. SSRIs. anxiety. renal impairment. dry mouth. sweating. flatulence Potential abuse. or opoids or acute intoxication with alcohol opoids and psychoactive drugs. confusion. hepatic impairment. headache. tachycardia. Use cautiously with pregnancy. lactation.

opoids. texture. pregnancy. orientation. acute intoxication with alcohol. concomitant use of CNS depressants or MAOIs. psychotropic drugs or other centrally acting analgesics. seizures. bowel sounds. lesions. BP. affect. Pulmonary auscultation. LFTs. bilateral grip strength. renal ore hepatic impairment. past or present history of opoid addiction y Physical Skin color. renal function tests . normal output.Drug Interactions y Devreased effectiveness with carbamazepine y Increased risk of tramadol toxicity with MAOIs or SSRIs Nursing Considerations Assessment y History Hypersensitivity to tramadol. lactation. reflexes.

drowsiness. Warning: Limit use in patients with past or present history of addiction to or dependence on opoids. severe constipation. lighting. Teaching points y y You may experience these side effects: dizziness. impaired visual acuity (avoid driving or performing tasks that require alertness). .) if sweating or CNS effects occur. (lie quietly. dizziness. loss of appetite. eat frequent small meals) Repot severe nausea.Interventions y Control environment (temperature. sedation. nausea.

C. Celecoxib Brand name Patient s Dosage Classification Celebex 100 mg PO bid Analgesic (nonopoid) NSAID Specific COX-2 enzyme inhibitor y acute and long term treatment of Signs and symptoms of rheumatoid arthritis and osteoarthritis y reduction of the number of colorectal polyps in familial adenomatous polyposis (FAP) y management acute pain y treatment of primary dysmenorrhea y relief of signs and symptoms of ankylosing spondylitis y Relief of signs and symptoms of juvenile rheumatoid arthritis. Indication .

may enter breast milk Excretion Bile. which protects the lining of the GI tract and has blood clotting and renal functions. if no effect. may increase to 200 mg/day PO bid as needed. . which is activated I inflammation to cause the signs and symptoms associated with inflammation.. suggest another therapy. after 6week. t ½ : 11 hours Distribution Crosses placenta.Action Analgesic and anti-inflammatory activities related to inhibition of the COX-2 enzyme. y acute pain. dysmenorrheal: 400mg. urine Dosage and Administration Adults Initially. 100mg PO bid. Pharmacokinetics Peak Route Onset 3 hours Oral Slow Metabolism Hepatic. then 200mg PO bid y FAP: 400mg PO bid y Anyklosing spondylitis: 200mg/day PO. does not affect the COX-1 enzyme.

pregnancy (third trimester). CVA Dermatologic Rash. dyspepsia. celecoxib. dizziness. dizziness. dry mucous membranes. flatulence. tiredness. agranulocytosis. eosinophilia. sweating. NSAID's or aspirin. ophthalmologic effects Cardiovascular MI. granulocytopenia. menorrhagia Others Peripheral edema. aplastic anemia. pruritis. significant renal impairment. abdominal pain. decreased Hgb or Hct. Adverse Reactions and Side effects Central Nervous System Headache. leucopenia. lactation. thrombocytopenia. bone marrow depression. hepatic and CV condition.Contraindications Contraindicated with allergies to sulfonamides. somnolence. fatigue. insomnia. stomatitis Gastrointestinal Nausea. GI bleed Hematologic Neutropenia. tinnitus. Precaution Use cautiously with impaired hearing. anaphylactoid reactions to anaphylactic shock . pancytopenia.

y Increased risk of GI bleeding with long term use of alcohol. serum electrolytes. impaired hearing. renal function tests. ophthalmologic and audiometric evaluation. Pulmonary edema. Monitor patient closely and reduce warfarin dose as appropriate. allergies hepatic and CV conditions. y Physical Skin color and lesions. reflexes. Respiratory. Nursing Considerations Assessment y History Renal impairment. peripheral sensation. lactation and pregnancy. LFT s. smoking. . adventitious sounds. CBC. y Increased lithium level and toxicity. orientation. liver evaluation.Drug Interactions y Increased risk of bleeding if taken concurrently with warfarin.

y Administer drug with food or after meals if GI upset occurs. and rest). do not increase dosage.g. induction of emesis. positioning. itching. y Report sore throat. y You may experience these side effects: Dizziness. y Arrange for periodic ophthalmologic examination during long term therapy. drowsiness (avoid driving or the use of dangerous machinery while taking this drug). GI Bleeding. . monitor accordingly. swelling in ankles or fingers. Warning: If overdose occurs. supportive therapy. institute emergency procedures-gastric lavage. y Establish safety measures if CNS or visual disturbances occur. fever. positioning. warmth. y Provide further comfort measures to reduce pain (e. rash. environmental control) and t reduce inflammation (e. changes in vision.g.Interventions Block Box warning: Be aware that the patient maybe at increased risk for CV events. Client/ Family Teaching y Take only the prescribed dosage.

. Selectively blocks the binding Angiotensin II to specific tissue receptors found in the vascular smooth muscle and adrenal gland. Olmesartan medoxomil Brand name Patient s Dosage Classification Indication Action Benicar 20 mg/ day PO as a once-daily dose Angiotensin II receptor antagonist Antihypertensive Treatment of hypertension. alone or in combination with other hypertensives.D. this action blocks the vasoconstricting effect of the reninangiotensin system as well as the release of aldosterone leading to decreased BP. may prevent the vessel remodeling associated with the development of atherosclerosis.

pregnancy (use during the second or third trimester can cause injury or death to the fetus. Pediatric Patients Safety and efficacy not established. hypovolemia. T 1/2 : 13hours Distribution Crosses placenta. . mat titrate to 40 mg/day if needed after 2 weeks. salt depletion.Pharmacokinetics Route Onset Peak Oral Varies 1-2 hours Metabolism Hydrolyzed in GI tract. Precaution Use cautiously with renal impairment. enters breast milk Excretion Feces. urine Dosage and Administration Adults 20 mg/day as a once-daily dose. Contraindications Contraindicated with hypersensitivity to any component of drug.

urticaria. fatigue. dizziness. pruritus. inflammation. rhinitis. constipation. hypertriglycemia URI symptoms. alopecia. flulike symptoms. syncope. dry skin Diarrhea.Adverse Reactions and Side effects Central Nervous System Cardiovascular EENT Gastrointestinal Hematologic Respiratory Others Headache. dental pain Increased CPK. hyperglycemia. bronchitis. tachycardia Rash. pharyngitis. abdominal pain. muscle weakness Hypotension. cough. sinusitis. hematuria. nausea. dry mouth. Back pain. arthritis .

y Monitor patient closely in any situation that may lead to decreased in BP secondary to reduction in fluid volume. hepatic or renal impairment hypovolemia. turgor. Black Box Warning: ensure that patient is not pregnant before beginning therapy. lactation. R. reflexes. y Physical Interventions Administer without regard to meals. BP. respiratory auscultation. affect. renal function tests. diarrhea.excessive perspiration. y . The blockage of the renin-angiotensin system following the surgery can produce problems. Warning: alert the surgeon and mark the patient s chart with notice that the olmesartan is being taken. vomiting. Suggest the use of barrier birth control while using olmesartan. Skin lesions. Depression of the renin-angiotensin system in infants is potentially very dangerous. excessive hypotension can occur. body temp.Nursing Considerations Assessment y History Hypersensitivity to any component of the drug. y Find an alternate method of feeding infant if given to a nursing mother. dehydration. serum electrolytes. salt depletion. pregnancy. Hypotension may be reversed with volume expansion. fetal injury and deaths have been reported. LFTs.

chills. . vomiting diarrhea (proper nutrition is important. Do not stop taking this drug without consulting your health care provider. y Take special precautions to maintain your fluid intake and safety precautions in any situations that night cause a loss of fluid volumeexcessive perspiration.Client/ Family Teaching y Take drug without regard of meals. if you become pregnant or desire to become pregnant. consult dietician o maintain nutrition). dizziness. symptoms of the upper respiratory tract and cough (do not self medicate. consult your health care provider. excessive hypotension can occur. consult your health care provider if this becomes uncomfortable). y Report fever. vomiting. dehydration. y Use barrier method of birth control while using this drug. headache (medications may be available to help) nausea. pregnancy. diarrhea. and swelling. y You may experience these side effects: Dizziness (avoid driving a car or perform hazardous activitie0.

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