Presentation

Case Study

Submitted by: Balverde, Shaine Marie

General Objectives:

After analyzing this case study, aided with the concept of promoting health
and wellness, we will be able to comprehend what are the best nursing
interventions to be given to the client. Along with enhancing our skills and
developing a positive attitude towards our patient.

Specific objectives:
After analyzing this case study, We will be able to:
• Have an idea regarding the pt. demographic data.
• Know what are the anatomy and physiology related to the case.
• Provide proper nursing interventions to alleviate pt. suffering.
• Formulate NCP based on pt. need and her condition,
Assessment Summary/ Signs and Symptoms:

Pt. X, 47yr old, Female, Single. PTA, pt. rushed to Central Visayas Health due
to Sudden onset of difficulty breathing, progressed to loss of consciousness, 2 days
cough, no fever. Vaccinated no booster dose, Intubated with ETT 7mm cuffed and
fixed @ level 18cm, ECE.O2 Sat 68% at room air. Skin warm, good turgor.
+ anisocoric pupils but reactive, + rales, distinct S1 and S2, tachycardic. GCS 3- GCS
9 (E3,M6, V1) No lab tests taken nor imaging. Pt. referred to SWU-MC.
Disease Definition/Description: Cardioembolic
Stroke
Cardioembolic stroke is defined as presence of a potential intracardiac
source of embolism in the absence of cerebrovascular disease in a patient with
nonlacunar stroke. It is responsible for approximately 20% of all ischemic
strokes. There is no “gold standard” for this diagnosis. Clinical features
suggestive of cardioembolic etiology include atrial dysrhythmia and sudden
onset of neurologic deficits at their maximum. Embolic strokes may be more
susceptible to hemorrhagic conversion (seen on CT in 20% of cardioembolic
strokes), possibly due to spontaneous thrombolysis and reperfusion into the
infarct.
Disease Definition/Description:

Myocardial ischemia occurs when blood flow to your heart is reduced,

preventing the heart muscle from receiving enough oxygen. The reduced
blood flow is usually the result of a partial or complete blockage of your
heart's arteries (coronary arteries).

Myocardial ischemia, also called cardiac ischemia, reduces the heart muscle's
ability to pump blood. A sudden, severe blockage of one of the heart's artery
can lead to a heart attack. Myocardial ischemia might also cause serious
abnormal heart rhythms.

Treatment for myocardial ischemia involves improving blood flow to the heart
muscle. Treatment may include medications, a procedure to open blocked
arteries (angioplasty) or bypass surgery.
 Risk Factors:

• Atrial Fibrillation
• Heart failue with reduced ejection fraction
• Left atrium\left atrial appendage clot
• Infective Endocarditis
• Paradoxical embolization via atrial septal abnormalities
• Aortic arch atheroma
• Prosthetic heart valves

Clinical Manifestation:

Certain clinical features are suggestive of cardioembolic infarction, including

sudden onset to maximal deficit, decreased level of consciousness at onset,
Wernicke’s aphasia or global aphasia without hemiparesis, a Valsalva manoeuvre at
the time of stroke onset, and co-occurrence of cerebral and systemic emboli.
Anatomy and Physiology:
Cardiovascular System

The functions of the heart are as

follows:
• Managing blood supply.
• Producing blood pressure.
• Securing one-way blood flow.
• Transmitting blood.

Anatomy of the Heart

The cardiovascular system can

be compared to a muscular
pump equipped with one-way
valves and a system of large and
small plumbing tubes within
which the blood travels.
Weight. Approximately the size of a person’s fist, the hollow,
cone-shaped heart weighs less than a pound.
Mediastinum. Snugly enclosed within the inferior mediastinum,
the medial cavity of the thorax, the heart is flanked on each side
by the lungs.
Apex. It’s more pointed apex is directed toward the left hip and
rests on the diaphragm, approximately at the level of the fifth
intercostal space.
Base. Its broad posterosuperior aspect, or base, from which the
great vessels of the body emerge, points toward the right
shoulder and lies beneath the second rib.
Pericardium. The heart is
enclosed in a double-walled sac
called the pericardium and is the
outermost layer of the heart.
Fibrous pericardium. The loosely
fitting superficial part of this sac
is referred to as the fibrous
pericardium, which helps protect
the heart and anchors it to
surrounding structures such as
the diaphragm and sternum.
Serous pericardium. Deep to the
fibrous pericardium is the
slippery, two-layer serous
pericardium, where its parietal
layer lines the interior of the
fibrous pericardium.
The heart muscle has three layers and they
are as follows:

Epicardium. The epicardium or the visceral

and outermost layer is actually a part of the
heart wall.
Myocardium. The myocardium consists of
thick bundles of cardiac muscle twisted and
whirled into ringlike arrangements and it is
the layer that actually contracts.
Endocardium. The endocardium is the
innermost layer of the heart and is a thin,
glistening sheet of endothelium hat lines the
heart chambers.
Pathophysiology:
Laboratory\Diagnostic Studies

Date Type of Exam Patient’s Results Normal Values Significance/Interpretation

HematologySpecific Examination:
______________
08\11\22 Complete Blood Count
WBC Count 25.63 4.40-11.0 -Pt. CBC result indicate a
Neutrophils 93.0 37.00-80.00 range of conditions,
Lymphocytes 2.3 10.00-50.00 including infections,
inflammation, injury and
immune system disorders.
-Severe or chronic low
counts can indicate a
possible infection or other
signficant illness

BUN+ Creatinine -high levels of ALT may be a

sign of liver damage from
Alt 50.80 0-41 hepatitis, infection,
cirrhosis, liver cancer, or
other liver diseases.
 Defining Nursing Scientific Plan of Care Nursing Interventions Rationale
Characteristics Diagnosis Analysis
Subjective: Ineffective Ineffective airway Short Term: Independent: 1.Upright position limits abdominal
airway clearance occurs After 3-4 hours 1. Position the patient upright if contents from pushing upward and
clearance when an artificial of nursing tolerated. Regularly check the inhibiting lung expansion. This position
airway is used intervention, pt. patient’s position to prevent promotes better lung expansion and
Objective: because normal will be able to: sliding down in bed. improved air exchange.
mucociliary 2. Perform nasotracheal 2.Suctioning is needed when patients
*Dsypnea transport -Patient will suctioning as necessary, are unable to cough out secretions
*facial grimace mechanisms are demonstrate especially if cough is ineffective. properly due to weakness, thick
*Diminished bypassed and increased air 3.Encourage patient to increase mucus plugs, or excessive or
breath impaired. Nursing exchange. fluid intake to 3 liters per day tenacious mucus production.
Vitals signs as assessment and -Demonstrate within the limits of cardiac 3.Fluids help minimize mucosal drying
follows: intervention are reduction of reserve and renal function. and maximize ciliary action to move
the keys to congestion. 4.Educate patient on coughing, secretions.
BP: 260/140 maintaining airway -Demonstrate deep breathing, and splinting 4.Patient will understand the
mmHg patency in the behaviors to techniques. underlying principle and proper
HR:157 bpm patient with an improve airway. 5. Provide oral care every 4 techniques to keep the airway clear of
RR: 25 cpm artificial airway in hours. secretions.
Temp: 37 place. Long Term: Collaborative: 5.Oral care freshens the mouth after
O2 Sat: 68% After 3days of 1.Maintain humidified oxygen as respiratory secretions have been
Reference: nursing prescribed. expectorated.
https://pubmed.ncb Intervention pt. 2.Give medications as Collaborative: 1.Increasing humidity
i.nlm.nih.gov/3547 will be able to: prescribed, such as antibiotics, of inspired air will reduce thickness of
341/#:~:text=Ineffe mucolytic agents, secretions and aid their removal. 2.A
ctive%20airway -Cope with the bronchodilators, expectorants, variety of medications are prepared to
%20clearance possible effects noting effectiveness and side manage specific problems. Most
%20occurs of the effects. promote clearance of airway
%20when,an medication. 3.Coordinate with a respiratory secretions and may reduce airway
%20artificial therapist for chest physiotherapy resistance. 3.Chest physiotherapy
%20airway%20in and nebulizer management as includes the techniques of postural
%20place. indicated. drainage and chest percussion to
4. Refer to the pulmonary mobilize secretions from smaller
clinical nurse specialist, home airways that cannot be eliminated by
health nurse, or respiratory means of coughing or suctioning.
therapist as indicated. 4.Consultants may be helpful in
Reference: ensuring that proper treatments are
https://nurseslabs.com/ineffectiv met.
e-airway-clearance/ Reference:https://nurseslabs.com/
ineffective-airway-clearance/
 Defining Nursing Scientific Plan of Care Nursing Interventions Rationale
Characteristics Diagnosis Analysis
Subjective: Risk for Activity intolerance Short Term: Independent: Independent:
activity can be described After 8hrs of 1. Discuss with S/O the 1.Understanding this relationship can
Intolerance as insufficient nursing relationship of the illness or help with acceptance of limitations.
physiological or intervention, pt. debilitating condition and ability 2. It may interfere with client’s ability
Objective: psychological will be able to: to perform desired activity. to perform at a desired level of activity.
*Foot drop energy to -Identify 2. Note presence of medical
*dyspnea complete required alternative ways diagnosis or other regimen. Collaborative:
Vitals signs as or desired daily to maintain Collaborative: 1. A colaborative program with short
follows: activities. Activity desired activity 1. Implement physical therapy term achievable goals enhances
intolerance is a level. program in conjunction with the likelihood of success.
BP: 260/140 common side client and other team members. 2. to sustain activity level.
mmHg effect of heart Long Term: 2. Refer to appropriate 3. To improve client’s ability to
HR:157 bpm failure and can be After 4days of resources for assistance and participate in desired activities.
RR: 25 cpm related to nursing equipment, as needed.
Temp: 37 generalized intervention, pt. 3. Assist client/SO with planning
O2 Sat: 68% weakness and will be able to for changes that may become
difficulty resting participate in necessary.
and sleeping. A conditioning/reh
contributing factor abilitation
is often tissue program to
hypoxia caused by enhance ability
decreased cardiac to perform.
output.

Reference:
https://simplenur
sing.ph/nursing-
intervention-for-
activity-
intolerance/
 Defining Nursing Scientific Plan of Care Nursing Interventions Rationale
Characteristics Diagnosis Analysis
Subjective: Acute Acute confusion Short Term: Independent: Independent:
Confusion (delirium) can After 8hrs of 1. Orient patient to 1. Increased orientation ensures
befall in any age nursing surroundings, staff, necessary greater degree of safety for the
Objective: group, which can intervention, pt. activities as needed. patient.
*Change in evolve over a will be able to: 2. Modulate sensory exposure. 2. Increased levels of visual and
sensorium period of hours to -Patient regains Provide a calm environment; auditory stimulation can be
Vitals signs as days. Factors that normal reality eliminate extraneous noise and misinterpreted by the confused
follows: increase the risk orientation and stimuli. patient.
for delirium and level of 3. Give simple directions. Allow 3. This communication method can
BP: 260/140 confusional states consciousness. sufficient time for patient to reduce anxiety experienced in strange
mmHg can be categorized -Patient has respond, to communicate, to environment.
HR:157 bpm into those that diminished make decisions. 4. Challenges to the patient’s thinking
RR: 25 cpm increase baseline episodes of 4. Avoid challenging illogical can be perceived as threatening and
Temp: 37 vulnerability delirium. thinking. result in a defensive reaction.
O2 Sat: 68% including -Patient 5. Communicate patient’s status, 5.Recognize that patient’s fluctuating
underlying brain demonstrates cognition, and behavioral cognition and behavior is a hallmark
disease such as appropriate manifestations to all necessary for delirium and is not to be construed
dementia, stroke, motor behavior. providers. as patient preference for caregivers.
or Parkinson’s 6. Plan care that allows for 6. Disturbance in normal sleep and
disease and those Long Term: appropriate sleep-wake cycle. activity patterns should be minimized
that precipitate the After 5days of Collaborative: as those patients with nocturnal
disturbance like nursing 1. Encourage family/SO(s) to exacerbations endure more
infection, intervention, pt. participate in reorientation as complications from delirium.
sedatives, and will be able to: well as providing ongoing input. Collaborative:
immobility. The -Patient 2. Teach family to recognize 1. The confused patient may not
change is participates in signs of early confusion and completely understand what is
commonly caused activities of daily seek medical help. happening. Presence of family and
by a medical living (ADLs). 3. Assist the family and significant others may enhance the
condition, significant others in developing patient’s level of comfort.
substance coping strategies. 2. Early intervention prevents long-
intoxication, or term complications.
medication side 3. The family needs to let the patient
effect. do all that he or she is able to do to
Reference: maximize the patient’s level of
https://nurseslab Reference: functioning and quality of life.
s.com/acute- https://nurseslabs.com/acute-
confusion/ confusion/#goals_and_outco Reference:
mes https://nurseslabs.com/acute-
confusion/#goals_and_outcomes
 Drug Classification Mechanism of Indication Contraindication Adverse Effects Nursing
Action Responsibilities
Generic Name: Beta-lactamase Piperacillin kills ZOSYN is You should not Tell your doctor if Monitor vital signs
Piperacillin/ inhibitors bacteria by indicated in adults use piperacillin you have ever had: qhr.
Tazobactam inhibiting the for the treatment of and tazobactam if Monitor signs of
synthesis of uncomplicated and you are allergic to: kidney disease (or if allergic reactions
Brand Name: bacterial cell complicated skin you are on dialysis); and anaphylaxis,
Zerbaxa, Zosyn walls. It binds and skin structure -piperacillin or any including pulmonary
preferentially to infections, other penicillin a bleeding or blood symptoms (tightness
Dosage: 4.5g specific penicillin- including cellulitis, antibiotic clotting disorder; in the throat and
Route: IV Drip binding proteins cutaneous (amoxicillin, chest, wheezing,
Frequency: (PBPs) located abscesses and ampicillin, an electrolyte cough dyspnea) or
q6hrs inside bacterial ischemic/diabetic Augmentin, imbalance such as skin reactions (rash,
Timing: 2-3hrs cell walls foot infections dicloxacillin, low levels of pruritus, urticaria).
caused by beta- oxacillin, penicillin, potassium in your
lactamase ticarcillin, or blood; Notify physician or
producing isolates others);tazobacta nursing staff
of Staphylococcus m; or cystic fibrosis; immediately if these
aureus. cephalosporin reactions occur.
antibiotic such as any type of allergy;
cefdinir (Omnicef), or
cephalexin
(Keflex), or others. if you are on a low-
salt diet.

Tell your doctor if you

are pregnant or
breastfeeding.
 Drug Classification Mechanism of Action Indication Contraindication Adverse Effects Nursing
Responsibilities
Generic Name: Macrolide In order to Azithromycin is The following The drug's active Monitor signs of
Azithromycin antibiotics replicate, bacteria indicated for the conditions are ingredient, pseudomembrano
require a specific treatment of contraindicated with this azithromycin, can us colitis, including
Brand Name: process of protein patients with mild drug. Check with your cause rare but diarrhea,
Dosage: Route: synthesis, enabled to moderate physician if you have serious side effects abdominal pain,
Frequency: by ribosomal infections caused any of the following such as severe or fever, pus or
Timing: proteins 6. by susceptible conditions: life-threatening mucus in stool,
Azithromycin binds strains of the diarrhea from an allergic reactions, and other severe
to the 23S rRNA of microorganisms infection with irregular heartbeats, or prolonged GI
the bacterial 50S listed in the Clostridium difficile Clostridium difficile- problems (nausea,
ribosomal subunit. It specific bacteria,low amount of associated diarrhea vomiting,
stops bacterial conditions below. magnesium in the blood and liver damage. heartburn).
protein synthesis by Recommended low amount of More common side
inhibiting the dosages, potassium in the blood, effects include
transpeptidation/tran duration of myasthenia gravis, a nausea or vomiting,
slocation step of therapy and skeletal muscle diarrhea and
protein synthesis considerations disorder, hearing loss abdominal pain.
and by inhibiting the for various torsades de pointes, a
assembly of the 50S patient type of abnormal heart
ribosomal subunit populations may rhythm, slow heartbeat
Label, 5. This vary among prolonged QT interval
results in the control these infections. on EKG, abnormal EKG
of various bacterial with QT changes from
infections 7, Label. birth
The strong affinity of a narrowing of the
macrolides, opening between the
including stomach and the small
azithromycin, for intestine
bacterial ribosomes, liver problems
is consistent with abnormal liver function
their broad‐ tests, inflammation of
spectrum the liver with stoppage
antibacterial of bile flow, a yellowing
activities 7 of the eyes or skin from
buildup of bilirubin
called jaundice.
 Drug Classificat Mechanism of Indication Contraindication Adverse Effects Nursing
ion Action Responsibilities
Generic The short term Hydrocortisone is contraindicated If you experience any Let pt. take
Name: corticoster effects of Hydrocortisone to the ff: inactive tuberculosis of these symptoms, medication with
Hydrocortis oids corticosteroids is used to treat herpes simplex infection of the eye call your doctor food to avoid
one are decreased certain medical an infection due to a fungus immediately: stomach upset.
vasodilation and conditions, intestinal infection caused by the sore throat, fever, Hbcg
permeability of such as roundworm Strongyloides chills, cough, or other Monitor pt. Hcg
Brand capillaries, as inflammation pheochromocytoma signs of infection level.
Name: well as (swelling), a condition with low thyroid seizures Monitor signs of
Cortef decreased severe allergic hormone levels diabetes, vision problems hypersensitivity
Dosage: leukocyte reactions, insufficiency of the hypothalamus swelling of the eyes, reactions or
50g migration to sites kidney and pituitary gland face, lips, tongue, anaphylaxis,
Route: of inflammation. diseases, low amount of potassium in the throat, arms, hands, including
IVTT Corticosteroids adrenal blood, psychotic disorder, brain feet, ankles, or lower pulmonary
Frequency: binding to the problems, injury, a disease with shrinking and legs symptoms
q6hrs glucocorticoid arthritis, weaker muscles called myopathy, swelling or pain in the (tightness in the
receptor asthma, blood increased pressure in the eye, stomach throat and chest,
mediates or bone wide-angle glaucoma, clouding of difficulty breathing or wheezing, cough,
changes in gene marrow the lens of the eye called cataracts, swallowing dyspnea) or skin
expression that problems, eye high blood pressure, chronic heart shortness of breath reactions (rash,
lead to multiple or vision failure, an ulcer from too much sudden weight gain pruritus, urticaria).
downstream problems, stomach acid, diverticulitis, surgical rash
effects over lupus, skin joining of two, parts of the intestine, hives
hours to days. conditions, and hardening of the liver, decreased itching
ulcerative kidney function, osteoporosis, a abnormal skin patches
colitis. condition of weak bones, in the mouth, nose, or
decreased calcification or density throat.
of bone, inherited deficiency of
argininosuccinate lyase, inherited
carbamoyl phosphate synthetase
deficiency, citrullinemia
infection caused by the varicella
zoster virus, measles, ornithine
carbamoyltransferase deficiency
arginase deficiency, exposure to
the measles, exposure to the
chickenpox, broken bone due to
disease or illness,malaria affecting
the brain, hyperammonemia
associated with N-acetylglutamate
synthase deficiency.
 Drug Classification Mechanism of Indication Contraindication Adverse Effects Nursing
Action Responsibilities
Generic Ipratropium is an Salbutamol Tell your doctor about Call your doctor at once Monitor respiratory
Name: Bronchodilator acetylcholine Nebuliser all your current if you have: rate, oxygen
Salbutamol s antagonist via Solution is medicines and any wheezing, choking, or saturation, and
blockade of indicated for use you start or stop other breathing lungs sounds
Brand Name: muscarinic in the routine using, especially: problems after using before and after
DuoNeb cholinergic management of any other inhaled this medicine; administration. If
receptors. chronic medicines or chest pain, fast heart more than one
Dosage: 1neb Blocking bronchospasm bronchodilators; rate, pounding inhalation is
Route: cholinergic unresponsive to digoxin;a diuretic or heartbeats or fluttering ordered, wait at
nebulization receptors conventional "water pill"; an in your chest; least 2 minutes
Frequency: decreases the therapy and the antidepressant - pain or burning when between
q6hrs production of treatment of amitriptyline, you urinate; inhalations. Use a
Timing: cyclic guanosine acute severe desipramine, increased thirst, spacer device to
monophosphate asthma. imipramine, doxepin, increased urination, improve drug
(cGMP). This nortriptyline, and hunger, dry mouth, fruity delivery, if
decrease in the others; a beta blocker breath odor, appropriate.
lung airways will - atenolol, carvedilol, drowsiness, dry skin,
lead to decreased labetalol, metoprolol, blurred vision, weight
contraction of the propranolol, sotalol, loss; or
smooth muscles. and others; or a MAO signs of low potassium -
inhibitor - leg cramps,
isocarboxazid, constipation, irregular
linezolid, phenelzine, heartbeats, fluttering in
rasagiline, selegiline, your chest, extreme
tranylcypromine, and thirst, increased
others or methylene urination, numbness or
blue injection tingling, muscle
weakness or limp
feeling.
 Drug Classification Mechanism of Indication Contraindication Adverse Effects Nursing Responsibilities
Action
Generic Name: Antiplatelet Clopidogrel is Use during a Clopidogrel is Clopidogrel may Monitor patient for signs
Clopidocrel agent an inhibitor of percutaneous contraindicated cause side effects. of thrombotic
platelet coronary in patients with a Tell your doctor if any thrombocytopenic
Brand Name: activation and intervention (PCI) known of these symptoms purpura (low platelet
Plavix aggregation for acute hypersensitivity are severe or do not count, neuro symptoms,
Dosage: 75mg/1tab through the coronary to clopidogrel or go away: renal dysfunction, fever).
Route: irreversible syndrome (ACS) any component excessive tiredness. Monitor for signs and
NGT binding of its and stable of the product. headache. symptoms of bleeding
Frequency: OD active ischemic heart dizziness. (urine, stool, hematoma,
Timing: pc lunch metabolite to disease. Primary Bleeding, GI nausea. epistaxis, petechiae).
the P2Y12 class prevention of bleeding, vomiting. May cause elevation of
of ADP thromboembolism intracranial stomach pain. serum liver enzymes–
receptors on atrial fibrillation. bleeding, peptic diarrhea. establish baseline
platelets. ulcer disease, nosebleed. enzymes and bilirubin
surgery, trauma levels.
 Drug Classification Mechanism of Action Indication Contraindication Adverse Effects Nursing
Responsibilities
Generic Name: Citicoline is taken Citicoline is taken by Cerebrovascular When taken by Citicoline was Instruct patient to
Citicoline by mouth or given mouth or given as an disorders, mouth: Citicoline is well tolerated in take the
as an injection to injection to help Cognitive POSSIBLY SAFE clinical trials. medication as
Brand Name: help memory loss memory loss due to disorder, Head when taken by Adverse effects prescribed.
Neurocoline due to aging, aging, improve vision in injury, mouth for up to 90 may include GI Teach the patient
Dosage: improve vision in people with glaucoma, Parkinson's days. Most people disturbances, that citicoline may
16mg/1tab people with and help with recovery disease who take citicoline transient be taken with or
Route: NGT glaucoma, and in stroke patients. It is by mouth don't headaches, without food.
Frequency: BID help with recovery also used for Alzheimer experience side hypotension, Monitor for
in stroke patients. disease, Parkinson effects. But some tachycardia, adverse effects;
It is also used for disease, bipolar people can have bradycardia, and instruct patient to
Alzheimer disease, disorder, lazy eye, and side effects such restlessness. report immediately
Parkinson disease, other conditions of the as trouble sleeping if he/she develops
bipolar disorder, brain. (insomnia), chest tightness,
lazy eye, and other headache, tingling in mouth
conditions of the constipation, and throat,
brain. diarrhea, nausea, headache,
stomach pain, diarrhea and
blurred vision, blurring of vision.
chest pains, and
others. There isn't
enough reliable
information to know
if taking citicoline
by mouth long-term
is safe or what the
side effects might
be.
 Drug Classification Mechanism of Indication Contraindication Adverse Effects Nursing Responsibilities
Action
Generic Name: Proton pump It suppresses It relieves Omeprazole is Primary adverse Advise patient to avoid
Omeprazole inhibitor (PPI) stomach acid symptoms such as contraindicated in effects reported in alcohol and foods that
secretion by heartburn, patients with a drug labeling may cause an increase
Brand Name: specific inhibition difficulty history of include headache, in GI irritation. Instruct
Prilosec and of the H+/K+- swallowing, and hypersensitivity abdominal pain, patient to report
Prilosec OTC ATPase system cough. This to the drug or any nausea, diarrhea, bothersome or
Dosage: found at the medication helps excipients from vomiting, and prolonged side effects,
40mg secretory surface heal acid damage the dosage form. flatulence in including skin problems
Route: of gastric parietal to the stomach According to adults. (itching, rash) or GI
IVTT cells. Because and esophagus, Product labeling, effects (nausea,
Frequency: this enzyme helps prevent omeprazole is diarrhea, vomiting,
OD system is ulcers, and may contraindicated in constipation, heartburn,
regarded as the help prevent patients taking flatulence, abdominal
acid (proton, or cancer of the dosage forms pain).
H+) pump within esophagus. containing
the gastric Omeprazole rilpivirine.
mucosa, belongs to a class
omeprazole of drugs known as
inhibits the final proton pump
step of acid inhibitors (PPIs).
production.
 Drug Classification Mechanism of Action Indication Contraindication Adverse Effects Nursing
Responsibilities
Generic Name: Analgesic Paracetamol has a Paracetamol is a Contraindications Side effects from The nurse should
central analgesic mild analgesic and to using paracetamol are assess for decrease
Paracetamol effect that is mediated antipyretic, and is acetaminophen rare but can in pain 30 minutes
through activation of recommended for include include: an allergic after IV
Brand Name: descending the treatment of hypersensitivity to reaction, which can administration and
Tylenol, Mapap serotonergic most painful and acetaminophen, cause a rash and 60 minutes after oral
or Panadol pathways. Debate febrile conditions, severe hepatic swelling. flushing, medication. If the
Dosage: exists about its for example, impairment, or low blood pressure patient's pain level is
500mg/tab primary site of action, headache including severe active and a fast heartbeat not acceptable, the
Route: which may be migraine, toothache, hepatic disease. – this can nurse should
PO inhibition of neuralgia, colds and sometimes happen investigate alternate
Frequency: prostaglandin (PG) influenza, sore when paracetamol treatment modalities.
q4 synthesis or through throat, backache, is given in hospital
Timing: an active metabolite rheumatic pain and into a vein in your
PRN fn fever influencing dysmenorrhoea. arm.
>38 cannabinoid
receptors.
 Drug Classification Mechanism of Action Indication Contraindication Adverse Effects Nursing
Responsibilities
Generic Chlorhexidine is a Chlorhexidine Chlorhexidine Oral irritation and It is the
Name: Antimicrobials cationic surfactant gluconate oral rinse gluconate oral rinse local allergy-type responsibility of the
Chlorehxidine synthetic biguanide is indicated for use should not be used symptoms have nurse managing the
with broad-spectrum between dental by persons who are been patient's care to
Brand Name: antibacterial and less visits as part of a known to be spontaneously assess the oral
Peridex and pronounced antifungal professional hypersensitive to reported as side mucosa and decide
PerioGard activity. It disrupts program for the Chlorhexidine effects associated on subsequent
Dosage: microbial cell treatment of gluconate or other with use of methods of oral
Route: membranes and gingivitis as formula ingredients. chlorhexidine hygiene in
Oral coagulates characterized by gluconate rinse. consultation with
Frequency: cytoplasmic proteins. redness and the medical team.
TID Chlorhexidine has a swelling of the The Oral
residual activity of gingivae, including Assessment Guide
several hours. gingival bleeding (OAG) can assist in
upon probing. determining the
patient's oral health
and function.
General Case of the Patient: Suspected Cardioembolic Stroke

Subjective Data

Objective Data *Dsypnea

*facial grimace
*Diminished breath
Vitals signs as follows:

BP: 260/140 mmHg

HR:157 bpm
RR: 25 cpm
Temp: 37
O2 Sat: 68%

Assessment/Nursing Diagnosis Ineffective airway clearance

Planning Pt. will be able to maintain airway patency.

Intervention

Activity Optimal positioning (sitting position)

Use of pillow or hand splints when coughing.
Use of abdominal muscles for more forceful cough.
Use of quad and huff techniques.
Use of incentive spirometry.
Importance of ambulation and frequent position changes.
Medication Instruct pt. to take medication as directed.

Environment Stress free environment conducive for maximum health regeneration.

Treatment Continue treatment based on referrals made by healthcare team.

Health Teachings Educate pt. with deep breathing exercises. Teach patients proper way of coughing.
Outpatient Referral Remind pt. to follow up check up especially when adverse effects are observed.
Diet Advised SO to provide nutritious meal to client, Avoid foods rich in preservatives,
Evaluation Pt. and SO understands the instructions given and shows positive attitude towards health care
providers and to the discharge plan.
Date Focus Time Data; Action; Reaction

08/11/22 Receiving Assessment 10:00 D: Received pt. asleep, lying in bed, intubated with ETT size7
cuffed and fixed @ level 18cm, attached to MV with settings of
AC modewith GCS score of 11/15 (E3 V1 M6). PERRLA 2/2;
with NGT closed tip; with FBC attached to uro bag. Vital signs
as ff: Bp: 180/110, HR: 157bpm, RR: 25cpm, O2 sat: 68% @
room air.

Hygiene/Bed bath D: Pt. hair is tangled; dry skin; voided and has soiled diaper.

A: Prepared all materials needed, positioned pt. in supine

position; removed gown of pt., performed bed bath, oral care,
and change soiled diaper, linens, gowns and underpads.

R: Pt. lying in bed well groomed, hair is combed.

Hgt monitoring D: Pt. lying in bed in supine position, awake.

A:Prepared all materials needed, explained the procedure to pt.,

pricked pt. fingertip, putting blood on glucose meter strip, then
cotton pad is placed on the punctured site.

End of shift 6:00 R: R: Seen pt. lying in bed; intubated with ETT size7 cuffed and
fixed @ level 18cm, attached to MV with settings of AC
modewith GCS score of 11/15 (E3 V1 M6). PERRLA 2/2; with
NGT closed tip; with FBC attached to uro bag. VS of: BP:
145/94, PR: 99. RR: 30, O2 sat: 98%, Temp: 36.32.