cva
TRANSCRIPT
I- INTRODUCTION
Cerebrovascular accident (CVA) or stroke is defined as a sudden loss of brain function
accompanied by neurological deficit. Strokes are caused by ischemia (oxygen deprivation)
resulting from a thrombus, embolus, severe vasospasm, or cerebral hemorrhage. Blood supply to
the brain is interrupted causing neurological deficits of sensation, movement, thought memory,
or speech. The loss of function can be temporary or permanent. Furthermore, differences in the
affected side of the brain have been identified. Clients with left-side CVA tend to have
communication deficits of aphasia, or inability to communicate. These clients tend to have
communication deficits of aphasia, or inability to communicate. These clients tend to be cautious
in behaviour and have intellectual and have intellectual impairments such as memory deficits or
loss of problem solving skills. A defect in the right visual field occurs, and hemiplegia occurs on
the right side.
On the other hand, HPN stage II Hypertension is high blood pressure. Stage 2 is of 160-
179 systolic and 100-109 diastolic. This is the moderate stage, which needs to be addressed if
present and brought down immediately to ensure a proper recovery. Diets rich in fats,
cholesterol, sodium, sugar are some of the factors. Added to that is smoking and lack of exercise.
What happens in CVA is that too much fat and cholesterol pile up in the blood vessels in the
brain and because of these, the pressure will increase inside the blood vessels and eventually the
blood vessels will lose its integrity and it will burst. It will eventually cause oxygen deprivation
in the brain. At five minutes of oxygen deprivation, the brain cells could die causing loss of
function to the affected part.
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Internationally, according to World Health Organization the frequency of
Cebrebrovascular accident worldwide found that in 2008, there are 6.15 million people in a year.
High blood pressure contributes to more than 12.7 million strokes worldwide. In the Philippines,
the morbidity rate is 206.3 cases per 100,000 populations according to Department of Health.
Here in Davao City, there are 2,248 people who have been affected by CVA in the year 2011
City Health Office.
This case caught the group’s interest because even though that Cerebrovascular accident
is common cause of illness and death here in the country and globally, our knowledge about the
illness is not that extensive that is why we choose to study the said case. On one hand, this case
is one of the most unusual cases that we’ve handled in our ward exposures. Furthermore, the
group sought to study and discover the occurrence of CVA, to be able to fully understand the
disease process itself.
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II- OBJECTIVES
General Objective
Within 3 days of duty in the neuro ward of Southern Philippine Medical Center, we will
be able to give safe and effective nursing care by relating and putting to use the knowledge that
has been imparted to us from the academe and that we would be able to pick a patient for our
case study and conduct a comprehensive case study of the patient’s condition.
Specific Objectives:
Cognitive
o to be able to define the complete diagnosis of the patient
o to conduct and present a cephalocaudal assessment of the patient
o to identify the developmental data of the patient
o be able to trace the signs, symptoms, etiology and pathophysiology of the
condition of our patient
o to present a comprehensive prognosis
o to able to create efficient nursing care plan based on actual high-risk health needs
o discuss the implications of the laboratory results of the patient as well as the
surgical procedure done
o to review and discuss the human anatomy and physiology of the digestive system,
focusing primarily on the affected organ and organ systems
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o to present a genogram that could trace any disease that could be hereditary to the
patient which might contribute to his present condition
Psychomotor
o to select a patient, conduct an interview and obtain data for our case study
o to choose and apply the different and related nursing theories that are appropriate
to the present health condition of the patient
o to present drug studies and discuss the different medications given to the patient
and why they were indicated for the patient
o to present the patient’s data, family background, health history and present health
condition
o to establish a good rapport with the patient to gain their trust and cooperation
Affective
o to give recommendations to the group, patient and Ateneo de Davao University’s
School of Nursing
o to provide health teachings to the client to achieve optimum wellness as well as
other relevant discharge orders.
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III- PATIENT’S DATA
Code Name: Patient B
Age: 57 years old
Sex: Male
Birthday: May 9, 1955
Birthplace: Manila
Address: Central Park Bangkal, Talomo Dist. Davao City
Nationality: Filipino
Civil Status: Single
Occupation: Stylist/Beautician
Religion: Roman Catholic
Educational attainment: High school Graduate
Hospital: Southern Philippines Medical Center
Date of Admission: November 24, 2012
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Time of Admission: 10:00 PM
Vital Signs upon Admission:
Blood Pressure: 280/140
Pulse: 80 bmp
Respiratory Rate: 18 cpm
Temperature: 36.5˚c
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IV- HEALTH HISTORY
Diagnosis: CVA Bleed left Capsulo Ganglionic , HPN II
Admitting Physician: Dr. Reco Prospero S. Delos Reyes
I. Past Health History
According to patient’s watcher, Pt B experienced motor accident three years ago
but he only got a bruise on his left leg. Patient B has no surgery history. He had his
Immunization but his watcher cannot tell if it’s complete or not. He has no known
allergies in terms of foods and medication according to his watcher. He was
diagnosed hypertension when he is still 31 years of age. On the same instance he also
had a history of mild stroke happened august last year. Patient B ignore his condition,
he don’t have maintenance for hypertension. Patient B is fond of eating fatty foods
such as humba as verbalized by his watcher.
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August of 2011, patient B had his first attack of Mild stroke. He was brought to
Davao Doctors Hospital. Upon being diagnosed patient B experienced difficulty in
speaking and complaint of having body weakness. After he diagnosed of Mild stroke
he again keeps on doing things that worsen his condition.
II. Present Health History
Last November 24, 2012, patient B attended a party at NCCC with his co
beautician. He suddenly lost her balance and fell on the floor. His friends
immediately rushed him to the clinic of NCCC but the NCCC clinic refer him to
Davao Doctors Hospital to have a thoroughly check up and examination. Three hours
Prior to admission patient B experienced sudden onset of decrease in sensorium
associated with right sided weakness thus brought to DDH, patient was managed as a
case of CVA bleed. Patient B was then subsequently transferred to SPMC for further
management. No relatives around with poor medical history. With GCS of 11 (E4,
V1, M6) with flattened left nasolabial fold, and with Babinski reflex
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88 84
40 52 57 59
LEGEND:
Deceased Male Patient B
Deceased Female DM
Hypertension Living Male
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Point to pt. Living Female
FAMILY HEALTH HISTORY
The Grandfather and Grand Mother of both sides already died but the watcher don’t have idea
what is the cause of death. The mother of our Patient 88 of age diagnosed with hypertension. On
the other hand his father 86 years of age also diagnosed with hypertension. Our patient is third in
the family. The third brother 52 years of age was diagnosed with hypertension. The younger
brother 59 years of age was diagnosed with DM they do not know if he has any maintenance
medications.
SOCIAL HISTORY
Patient B occasionally drinks and smoke after the beauty pageant event which he was one
of the team as make-up artist. He does not use illegal drugs. He rides jeepney from his house to
his different events and bus as transportation going in and out in the city proper. He owned a
beauty parlor and worked as beautician aside from that he owned small “karinderya” and he
personally cooks the foods. He lives at the Central Park Bangkal, Talomo Dist. Davao City.
According to the watcher he lives with his friends together. Sometimes, in his free time he
played mah-jong and cards with his fellow friends. According to the watcher Patient B goes
somewhere alone when they are not scheduled to have some make-up event. He is Roman
Catholic, he attend masses rarely. In the morning, he wakes up early to go to market and cook for
his “karinderya” and during afternoon he visit to his parlor and supervised his beautician.
NUTRITIONAL ASSESSMENT
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Patient B height is 5’4” and weight is 54kg. and his BMI is 19.46. He does not follow any
particular diet. He eats what he wanted to cook. He is fond eating fatty foods.
V. DEVELOPMENTAL DATA
Erikson’s Psychosocial Theory
Erikson's stages of psychosocial development as articulated by Erik Erikson explain
eight stages through which a healthily developing human should pass from infancy to late
adulthood. In each stage the person confronts, and hopefully masters, new challenges.
According to Erikson, these developmental stages consist of a series of normative conflicts that every
person must handle. The two opposing energies (developmental crisis) must be synthesized in a
constructive manner to produce positive expectations for new experiences. If the crisis is unresolved,
the person does not develop attitudes that will be helpful in meeting future developmental tasks. The
resolution of the task can be complete, partial or unsuccessful, the more the success of an individual has
at each developmental stage, the healthier the personality of the individual.
STAGE AGE CHARACTERISTICS ACHIEVED JUSTIFICATION
Adulthood
Generativity vs.
Stagnation
30-65 years
old
This stage takes place
during middle
adulthood between the
ages of approximately
30 and 65. During this
time, adults strive to
create or nurture
Being a stylist, an
event manager
and a person that
manage his own
parlor and
carenderia at the
age of 57, he is
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things that will outlast
them; often by having
children or
contributing to
positive changes that
benefits other people.
considered as a
part of the
Generativity vs.
Stagnation stage
of Erikson’s
Theory. Patient B
spends his time
wisely by
engaging in
helpful activities
such as
organizing
fashion and
modeling events
which displays a
person’s
creativity. He was
able to raise and
manage his own
carenderia which
contributes to the
society and
benefits the future
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generation.
Jean Piaget’s Cognitive developmental theory
Jean Piaget’s theory views intellectual development as a result of constant interaction between
environmental influences and genetically determined attributes. Piaget’s research focused on four
stages of intellectual growth during childhood, with emphasis on how a child learns and adapts what is
learned from the adult world.
STAGE AGE CHARACTERISTICS ACHIEVED JUSTIFICATION
FORMAL
OPERATIONAL
12 years-
adulthood
This stage
begins at age
12 years and
lasts to
adulthood. The
person
develops adult
logic and is
able to reason,
from
conclusions,
plan for the
Patient B
considers the
possible
outcomes and
consequences of
his actions. He
left his hometown
and decided to
start a new life in
Davao City
without
hesitations
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future, think
abstractly and
build ideas.
because he knew
the reason for
making his
decision. He was
able to find a
good job and
manage his own
business. While
he was in the
hospital during
his recovery, he
stated that he is
now more careful
about the foods
that he will eat
and decided to
have check-ups.
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DEVELOPMENTAL TASK THEORY
According to Havighurst, learning is basic to life and that people continue to learn throughout life. He
described growth and development as occurring during six stages, each associated with six to ten tasks
to be learned. The developmental task is one that arises at a certain period in our lives, the successful
achievement of which leads to happiness and success with later tasks; while failure leads to
unhappiness, social disapproval, and difficulty with later tasks.
STAGE AGE CHARACTERISTICS ACHIEVED JUSTIFICATION
Middle Age Ages 40–60 *Assisting teenage
children to become
responsible and happy
adults.
* Achieving adult
social and civic
responsibility.
PASSED
PASSED
Patient B treats
his younger co-
stylists like his
own relative. His
friends and co-
stylists call her
“Mommy”. They
stated that Patient
B was their
helping hand and
their “teacher”.
He was able to
carry out his role
as an adult and an
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* Reaching and
maintaining
satisfactory
performance in one’s
occupational career.
* Developing adult
leisure time activities.
PASSED
PASSED
individual of the
society. He
participates in
baranggay
activities, and
especially he
participates in
organizing events
such as modeling
and contests.
He managed his
own carenderia
and parlor well.
His earnings were
good and he
makes sure that
he spends his
money wisely.
He enjoys
performing some
leisure activities.
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* Relating oneself to
one’s spouse as a
person.
* To accept and adjust
He goes
“majong” but
most of the time
he visits his
parlor where he
chats with his
clients and
workers, watch
TV, listen to
music and reads
magazine.
He wasn’t able to
get married; He
doesn’t have
someone whom
he spends his life
with aside from
his friends and
co-workers.
He knew that
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to the physiological
changes of middle
age.
* Adjusting to aging
parents.
PASSED
PASSED
physical and
physiologic
activity gradually
decreases from
time to time.
Somehow, he
accepts that the
process of aging
and degenerative
changes is just
but a normal to
all.
Patient B was
able to detach
from his parents
and has his own
house separated
from his parents.
He accepted that
his parents were
aging and
someday he will
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have to live his
life without them
all time.
VI- PYHSICAL ASSESSMENT
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General Survey:
At 8:00 PM on December 07, 2012, Physical Assessment was done. Patient B was lying on bed
awake with watcher on side. Patient B don’t have clothes, he only use blanket to cover his body.
Patient B is wearing diaper. Patient B is ectomorph in body built. Right side of his body is weak
and unable to move voluntarily upon assessment. Language and communication is poor and
impaired.
Vital Signs:
Blood Pressure-140/80
Pulse-82
Respiratory Rate-20
Temperature- 36.4˚c
Anthropometric Measurement:
Weight-53 kilograms
Height-5’4
Neurological Exam:
CN I- Patient B, able to identify the smell of alcohol.
CN II- Patient B, was not able to see clearly the far objects and stated he is nearsighted.
CN III, IV& VI- responsive; equal pupil size; eyes moves smoothly.
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CN V- + sensation
CN VII-+ hearing
CN VIII- patient can hear
CN IX and CN X- + gag reflex
CN XII- + tongue deviation
Neurological assessment:
Level of consciousness: patient is only aroused to painful stimuli, and conversation is
unclear.
Glasgow coma scale:
Eye opening- score: 4
Best Verbal response- score: 1
Best Motor Response-score: 6 obey commands
Orientation- the patient is non-responsive on questions asked.
Communication:
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Patient has poor communication status. Patient is able to understand spoken
words. But response inappropriate. Speech is not clear and voice modulation is very low.
Skin
Skin is dry and warm to touch, with a poor skin turgor as evidenced by its springs back
slowly to normal state when pinched. With a capillary time of 3 seconds on both fingers and
toes. No presence of rashes, lesions, bruises, abrasions and pigmented spots upon inspection.
Hair is oily, nails are not trimmed.
Head
Head is normacephalic and is at midline with the abdomen. Hair is brown in color, oily
and scantly distributed. No dandruff noted. Lacerations, lesions, masses and tenderness are not
noted behind the ears and along the hairline at the neck.
Eyes
Eyes are symmetrical and almond shape. Eyebrows are evenly distributed with
back hair strands, eyebrows symmetrically aligned and equal in movement. Eyelashes are
equally distributed and curled slightly outward. Skin of the eyelids is intact; no discharges and
discoloration noted; lids close symmetrically while blinking, Anicteric sclera with some visible
capillaries noted. Conjuctivas are pale pink in color. No edema or tenderness over lacrimal gland
edema or tearing of lacrimal gland not noted. Iris is dark brown in color. No redness anad
secretions noted. Pupils are equally rounded. With the use of penlight, pupils are 2mm in
diameter upon exposure. Brisk eye response noted. Pupils dilate when looking at distant objects
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and constrict when looking at nearer objects. Pupils are equal in size, reactive to light and
accommodation. Peripheral vision is good for both sides. Patient did not use any corrective aids
such as glasses or contact lenses.
Ears
He has symmetrical external auricle with same color to facial skin. Top portion of the
auricle are aligned to the outer canthus of the eye. No Cerumen discharges noted upon
inspection.
Auricles are mobile, firm and not tender upon palpation, pinnae recoils after it is being
folded. No rashes, lesions and lacerations noted around and at the back of both ears. Auditory
status is normal as evidenced by patient is aroused to verbal stimuli.
Nose
Nose is symmetrical and at midline of the face, with uniform color. Nasolabial fold is
evident. Nasal septum is intact and found in midline, with pinkish mucosa. Nares are patent. No
unusual discharges noted.
Mouth
Patient has dry and slightly dark lips. Gums are slightly pale in appearance. His tongue is
pinkish. Patient can swallow food and masticate.
Neck
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Trachea is at midline. Head is not uniformly coordinated in movement since the patient
cannot move freely, but head can move slowly. Lymph nodes are not palpable. Anterior neck is
symmetrical at both sides with no masses noted. No masses also palpated on posterior neck.
There was no unusual enlargement.
Chest and Lungs
The patient has intact chest skin with uniform temperature. Chest is symmetrical. There is
an equal chest wall expansion with clear breath sounds, with rhythmic and effortless respiration.
Chest wall in is intact with no tenderness and masses noted. Breast are equal in size with dark
colored areola.
Heart
Carotid artery has symmetric pulse volumes upon palpation, and no presence of bruit
upon auscultation. Patient has regular heart rhythm and rate with no presence of murmurs.
Abdomen
The abdomen is flabby in appearance, uniform in color and is warm to touch. Abdomen
is not distended, no mass noted.
Upper extremity
Shoulders and arms are symmetrical with no deformity. Right arm is weak, cannot be
moved voluntarily and non-reactive to stimuli. Left arm has a normal movement and very
reactive to stimuli.
Lower Extremity
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Right leg is unable to move, and non-reactive ti stimuli. Left leg is normal in movement
and reactive to stimuli. Both feet are dry, callous noted on the soles of the feet. Nails are not
untrimmed and dirty.
Male Genitalia Assessment
Client wears an adult diaper.
VII- PATIENT’S DIAGNOSIS
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DEFINITION OF COMPLETE DIAGNOSIS
Cerebrovascular accident
Stroke or Cerebrovascular accident (CVA) results from sudden interruption of blood
supply to the brain, which precipitates neurologic dysfunctions lasting longer than 24
hours. Strokes are either ischemic, cause by partial or complete occlusion of a cerebral
blood vessel by cerebral thrombosis or embolism or hemorrhage.
Source:Lippincott Manual Nursing Practice handbook 3rd Edition Pgs 901-908
A stroke, or cerebrovascular accident (CVA), is the rapid loss of brain functions due to an
abnormal perfusion of brain tissue or disturbance in the blood supply to the brain. This
can be due to ischemia (lack of blood flow) caused by blockage (thrombosis, arterial
embolism), or a hemorrhage.As a result, the affected area of the brain cannot function,
which might result in an inability to move one or more limbs on one side of the body,
inability to understand or formulate speech, or an inability to see one side of the visual
field.
Source: http://en.wikipedia.org/wiki/Stroke
Cerebrovascular accident or stroke is sudden diminution or loss of consciousness,
sensation, and voluntary motion caused by rupture or obstruction of a blood vessel of the
brain.
Source:Merriam-Webster medical dictionary new edition by Roger W. Pease, Jr., Ph.D.
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Bleed Capsuloganglionic
Bleed Capsuloganglionic also known as the Capsuloganglionic Hemorrhage is the
hemorrhage into the basal ganglia and internal and external capsule of the brain.
Source: Dorland's illustrated medical dictionary - Volume 1914 - Page 422
Bleed Capsuloganglionic refers to the hemorrhage that occurs in the internal capsule of
the brain and the basal ganglia that usually marked by paralysis of the opposite limb,
sensory disturbance of half of the body and hemianopsia.
Source: Pathophysiology of Health Care Professionals 3rd Edition pages 561-566.
Bleed Capsuloganglionic (Capsuloganglionic hemorrhage)
HYPERTENSION STAGE II
Hypertension Stage II is more severe hypertension, stage 2 hypertension is a systolic
pressure of 160 mm Hg or higher or a diastolic pressure of 100 mm Hg or higher.
Source: Brunner and Suddhart’s textbook of Medical Surgical Nursing Pgs 685
Hypertension Stage IIalso known as Late High Blood Pressure or Severe high blood
pressure. A systolic blood pressure value of >160 or a diastolic blood pressure value
of>100. Stage 2 Hypertension is a serious form of high blood pressure, and requires
immediate treatment.
Source: http://highbloodpressure.about.com/od/glossary/g/s2_glos.htm
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Hypertension stage IIis also known as the severe hypertension where the mean arterial
pressure often rises to as high as 150 to 170 mm Hg, with diastolic pressures as high as
130 to 150 mm Hg and diastolic arterial p ressures sometimes as great as 250 mmHg.
Source: Guyton’s Textbook of MEDICAL PHYSIOLOGY 7th Edition by Arthur C. Guyton M.D
Pg 266
CVA Bleed Left Capsuloganglionic Hypertension II is a stroke that causes bleeding into the left
capsuloganglionic area due to a chronic severe hypertension; There is a rupture of a blood vessel
and hemorrhage into the brain tissue resulting in swelling of the brain, compression of the brain
contents or spasm of the adjacent blood vessels.
VIII- ANATOMY AND PHYSIOLOGY
The Human Nervous System
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The nervous system is one of the body’s principal control and integrating centers. In
humans, the nervous system serves three board functions: sensory, integrative, and motor. First,
it senses certain changes within the body and in the outside environment; this is its sensory
function. Second, it interprets the changes; this is the integrative function. Third, it responds to
the interpretation by initiating action in the form of muscular contractions or glandular
secretions; this is its motor function.
Through sensation, integration, and response, the nervous system represents the body’s
most rapid means of maintaining homeostasis. Its split-second reactions, carried out by nerve
impulses, can normally make the adjustments necessary to keep the body functioning efficiently.
A.) Central Nervous System (CNS)
The central nervous system is effectively the center of the nervous system, the
part of it that processes the information received from the peripheral nervous system.
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The CNS consists of the brain and spinal cord. It is responsible for receiving and
interpreting signals from the PNS and also sends out signals to it, either consciously or
unconsciously
The Nerve Cell
Nerve cells, called neurons, are responsible for conducting nerve impulses from
one part of the body to another. Neurons have two kinds of cytoplasmic processes:
dendrites and axons. Dendrites are usually highly branched, thick extensions of the
cytoplasm of the cell body. Their function is to conduct nerve impulses toward the cell
body. On the end of these dendrites lie the axon terminals, which ‘plug’ into a cell
where the electrical signal from a nerve cell to the target cell can be made. This ‘plug’
(axon terminal) connects into a receptor on the target cell and can transmit information
between cells.
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Axon, is usually a single long, thin process that is highly specialized and conducts
nerve impulses away from the cell body to another neuron or muscular or glandular
tissue.
Classification of Neurons:
1.) Afferent Neurons – transmit impulses from receptors in the skin, sense organs,
muscles, joints, and viscera to the CNS.
2.) Efferent Neurons – convey impulses from the brain and spinal cord to effectors,
which may be either muscles or glands, and from high to lower centers of the CNS.
3.) Interneurons – carry impulses from sensory neurons to motor neurons and are
located in the brain and spinal cord.
Spinal Cord
The spinal cord begins as a continuation of the medulla oblongata and terminates
at about the second lumbar vertebra. It is protected by the vertebral canal, meninges,
cerebrospinal fluid, and vertebral ligaments.
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31 pairs of spinal nerves rise along the spinal cord. These are “mixed” nerves
because each contain both sensory and motor axons. However, within the spinal
column,
all the sensory axons pass into the dorsal root ganglion where their cell
bodies are located and then on into the spinal cord itself
all the motor axons pass into the ventral roots before uniting with the
sensory axons to form the mixed nerves
A major function of the spinal cord is to convey sensory nerve impulses from the
periphery to the brain and to conduct motor impulses from the brain to the periphery.
Another, is to serve as a reflex center. It serves as a minor reflex center.
Brain
The brain receives sensory input from the spinal cord as well as from its own nerves (ex.
Olfactory and Optic nerves). It devotes most of its volume (and computational power) to
processing its various sensory inputs and initiating appropriate – and coordinated- motor outputs.
White Matter and Gray Matter
Both the spinal cord and the brain consist of:
White Matter – bundles of axons each coated with a sheath of myelin
Gray Matter – masses of the cell bodies and dendrites – each covered with synapses.
In the spinal cord, the white matter is at the surface, they gray matter inside.
The Meninges
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Both the spinal cord and brain are covered in three continuous sheets of connective tissue, the
meninges. From outside in, these are the
Dura mater – pressed against the bondy surface of the interior of the vertebrae and the
cranium
Arachnoid
Pia Mater
The region between the arachnoid and pia mater is filled with cerebrospinal fluid (CSF)
a.) Brain Stem
1.) Medulla Oblongata
The medulla contains all ascending and descending tracts that
communicate between the spinal cord and various parts of the brain. These tracts
constitute the white matter of the medulla.
Rhythmically stimulate the intercostals muscles and diaphragm making breathing
possible
Regulate heartbeat
Regulate the diameter of arterioles thus adjusting blood flow
2.) Pons
The pons seems to serve as a relay station carrying signals from various
parts of the cerebral cortex to the cerebellum. Nerve impulses coming from the
eyes, ears, and touch receptors are sent on the cerebellum. The pons also
participates in the reflexes that regulate breathing.
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The reticular formation is a region running though the middle of the brain
stem ( and on into the midbrain). It receives sensory input (eg. Sound) from higher in
the brain and passes these back up to the thalamus. The reticular formation is
involved in sleep, arousal (and vomiting)
3.) Midbrain
The midbrain (mesencephalon) occupies only a small region in humans (it
is relatively much larger in “lower” vertebrates). We shall look at three features:
The reticular formation: collects inpur from higher brain centers and passes it on
to motor neurons.
The substantia nigra: helps “smooth” out body movements;
The ventral tegmental area (VTA): packed with dopamin-releasing nurons that:
o Are actuvated by nicotinic acetylcholine receptors and
o Whose projections synapse deep within the forebrain.
The VTA seems to be involved in pleasure: nicotine, amphetamines and cocaine
bind to and activate its dopamine-releasing neurons and this may account for their
addictive qualities.
b.) Diencephalon
1.) Thalamus
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All sensory input (except for olfaction) passes through these paired structures
on the way up to the somatic-sensory regions of the cerebral cortex and then
returns to them from there.
Signals from the cerebellum pass through them on the way to the motor areas
of the cerebral cortex.
2.) Hypothalamus
The seat of the autonomic nervous system. Damage to the hypothalamus is
quickly fatal as the normal homeostasis of body temperature, blood chemistry,
etc. goes out of control.
c.) Cerebellum
The cerebellum consists of two deeply-convoluted hemispheres. Although it
represents only 10% of the weight of the brain, it contains as many neurons as all
the rest of the brain combined. Its most clearly-understood function is to
coordinate body movements. People with damage to their cerebellum are able to
perceive the world as before and to contract their muscles, but their motions are
jerky and uncoordinated.
It appears to be a center for learning motor skills (implicit memory). Laboratory
studies have demonstrated both long-term potentiation (LTP) and long-term
depression (LTD) in the cerebellum
The Cerebral Hemispheres
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Each hemisphere of the cerebrum is subdivided into four lobes visible from the outside:
1.) Frontal lobe – conscious thought; damage can result in mood changes
2.) Parietal lobe – plays important roles in integrating sensory information from various
senses, and in the manipulation of objects; portions of the parietal love are involved
with visuospatial processing
3.) Occipital lobe – sense of sight; lesions can produce hallucinations
4.) Temporal lobe – senses of smell and sound, as well as processing of complex stimuli
like face and scenes.
B.) Peripheral Nervous System (PNS)
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The peripheral nervous system branches outside of the central nervous system and
is comprised of nerves and neurons that transmit information to and from the
brain. The peripheral nervous system is further divided into two parts called the
somatic nervous system and the autonomic nervous system.
a.) The Sensory-Somatic Nervous System
The sensory somatic nervous system consists of:
12 pairs of cranial nerves and
31 pairs of spinal nerves
37 | P a g e
The Spinal Nerves
All of the spinal nerves are “mixed”;that is, they contain both sensory and motor neurons.
All our conscious awareness of the external environment and all our motor activity to cope with
it operate through the sensory-somatic division of the PNS.
b.) The Autonomic Nervous System
The autonomic nervous system consists of sensory neurons and motor neurons that run between
the central nervous system (especially the hypothalamus and medulla oblongata) and various
internal organs such as the :
Heart
Lungs
Viscera
Glands (Both endocrine and exocrine)
It is responsible for monitoring conditions in the internal environment and bringing about
appropriate changes in them. The contraction of both smooth muscle and cardiac muscle is
controlled by motor neurons of the autonomic system.
38 | P a g e
The actions of the autonomic nervous system are largely involuntary (in contrast to those of the
sensory-somatic system). It also differs from the sensory-somatic system in using two groups of
motor neurons to stimulate the effectors instead of one.
The first, the preganglionic neurons, arise in the CNS and run to a ganglion in the body.
Here they synapse with
Postganglionic neurons, which run to the effector organ (cardiac muscle, smooth
muscle, or a gland)
The autonomic nervous system has two subdivisions, the
Sympathetic Nervous System
Parasympathetic Nervous System
The Sympathetic system activates and prepares the body for vigorous muscular activity. Stress.
And emergencies. While the Parasympatheticsystem lowers activity, operates during normal
situations, permits digestion, and conservation of energy.
Major Blood Vessels of the Brain
39 | P a g e
Normal function of the brain’s control centers is dependent upon adequate supply of
oxygen and nutrients through a dense network of blood vessels. Blood is supplied to the brain,
face, and scalp via two major sets of vessels: the right and left common carotid arteries and the
right and left vertebral arteries.
The common carotid arteries have two divisions. The external carotid arteries supply the
face and scalp with blood. The internal carotid arteries supply blood to the anterior three-fifths of
cerebrum, except for parts of the temporal and occipital lobes. The vertebrobasilar arteries
supply the posterior two-fifths of the cerebrum, part of the cerebellum, and the brain stem.
Any decrease in the flow of blood through one of the internal carotid arteries brings about some
impairment in the function of the frontal lobes. This impairment may result in numbness,
weakness, or paralysis on the side of the body opposite to the obstruction of the artery.
Occlusion of one of the vertebral arteries can cause many serious consequences, ranging from
blindness to paralysis.
Circle of Willis
40 | P a g e
At the base of the brain, the carotid and vertebrobasilar arteries form a circle of
communicating arteries known as the circle of Willis.
From this circle otheir arteries – the anterior cerebral artery (ACA), the middle cerebral
artery (MCA), the posterior cerebral artery (PCA) – arise and travel to all parts of the brain.
Posterior Inferior Cerebellar Arteries (PICA), which branch from the vertebral arteries, are not
shown.
Because the carotid and vertebrobasilar arteries form a circle, if one of the main arteries is
occluded, the distal smaller arteries that it supplies can receive blood from the other arteries
(collateral circulation).
Anterior Cerebral Artery
The anterior cerebral artery extends upward and forward from the internal carotid artery. It
supplies the frontal lobes, the parts of the brain that control logical thought, personality, and
voluntary movement, especially the legs. Stroke in the anterior cerebral artery results in opposite
leg weakness. If both anterior cerebral territories are affected, profound mental symptoms may
result (akinetic mutism)
Middle Cerebral Artery
The middle cerebral artery is the largest branch of the internal carotid. The artery supplies a
portion of the frontal love and the lateral surface of the temporal and parietal lobes, including the
primary motor and sensory areas of the face, throat, hand and arm in the dominant hemisphere,
the areas of speech. The middle cerebral artery is the artery most often occluded in stroke.
41 | P a g e
Posterior Cerebral Artery
The posterior cerebral arteries stem in most individuals from the basilar artery but sometimes
originate from the ipsilateral internal carotid artery. The posterior arteries supply the temporal
and occipital lobes of the left cerebral hemisphere and the right hemisphere. When infarction
occurs in the territory of the posterior cerebral artery, it is usually secondary to embolism from
lower segments of the vertebral basilar system or heart.
Lenticulostriate Arteries
Small, deep penetrating arteries known as the lenticulostriate arteries branch form the middle
cerebral artery. Occlusions of these vessels or penetrating brancjes of the circle of Willis or
vertebral or basilar arteries are referred to as lacunar strokes.
The cells distal to the occlusion die, but since these areas are very small often only minor
deficits are seen. When the infarction is critically located, however, more severe
manifestations may develop, including paralysis and sensory loss. Within a few months of
the infarction, the necrotic brain cells are reabsorbed by macrophage activity, leaving a very
small cavity.
42 | P a g e
Renin-Angiotensin-Aldosterone System
The renin-angiotensin-aldosterone system (RAAS) plays an important role in regulating blood
volume and systemic vascular resistance, which together influence cardiac output and arterial
pressure. As the name implies, there are three important components to this system: 1) renin, 2)
angiotensin, and 3) aldosterone. Renin, which is primarily released by the kidneys, stimulates the
formation of angiotensin in blood and tissues, which in turn stimulates the release of aldosterone
from the adrenal cortex.
Renin is a proteolytic enzyme that is released into the circulation primarily by the kidneys. Its
release is stimulated by:
sympathetic nerve activation (acting via β1-adrenoceptors)
renal artery hypotension (caused by systemic hypotension or renal artery stenosis)
decreased sodium delivery to the distal tubules of the kidney.
Juxtaglomerular (JG) cells associated with the afferent arteriole entering the renal glomerulus are
the primary site of renin storage and release in the body. A reduction in afferent arteriole
pressure causes the release of renin from the JG cells, whereas increased pressure inhibits renin
release. Beta1-adrenoceptors located on the JG cells respond to sympathetic nerve stimulation by
releasing renin. Specialized cells (macula densa) of distal tubules lie adjacent to the JG cells of
the afferent arteriole. The macula densa senses the amount of sodium and chloride ion in the
tubular fluid. When NaCl is elevated in the tubular fluid, renin release is inhibited. In contrast, a
reduction in tubular NaCl stimulates renin release by the JG cells. There is evidence that
prostaglandins (PGE2 and PGI2) stimulate renin release in response to reduced NaCl transport
across the macula densa. When afferent arteriole pressure is reduced, glomerular filtration
43 | P a g e
decreases, and this reduces NaCl in the distal tubule. This serves as an important mechanism
contributing to the release of renin when there is afferent arteriole hypotension.
When renin is released into the blood, it acts upon a circulating substrate, angiotensinogen, that
undergoes proteolytic cleavage to form the decapeptide angiotensin I. Vascular endothelium,
particularly in the lungs, has an enzyme, angiotensin converting enzyme (ACE), that cleaves off
two amino acids to form the octapeptide, angiotensin II (AII), although many other tissues in the
body (heart, brain, vascular) also can form AII.
44 | P a g e
AII has several very important functions:
1. Constricts resistance vessels (via AII [AT1] receptors) thereby increasing systemic
vascular resistance and arterial pressure
2. Acts on the adrenal cortex to release aldosterone, which in turn acts on the kidneys to
increase sodium and fluid retention
3. Stimulates the release of vasopressin (antidiuretic hormone, ADH) from the posterior
pituitary, which increases fluid retention by the kidneys
4. Stimulates thirst centers within the brain
5. Facilitates norepinephrine release from sympathetic nerve endings and inhibits
norepinephrine re-uptake by nerve endings, thereby enhancing sympathetic adrenergic
function
6. Stimulates cardiac hypertrophy and vascular hypertrophy
The renin-angiotensin-aldosterone pathway is regulated not only by the mechanisms that
stimulate renin release, but it is also modulated by natriuretic peptides (ANP and BNP) released
by the heart. These natriuretic peptides acts as an important counter-regulatory system.
Therapeutic manipulation of this pathway is very important in treating hypertension and heart
failure. ACE inhibitors, AII receptor blockers and aldosterone receptor blockers, for example, are
used to decrease arterial pressure, ventricular afterload, blood volume and hence ventricular
preload, as well as inhibit and reverse cardiac and vascular hypertrophy.
45 | P a g e
IX- ETIOLOGY
Etiology is the study of the cause or origin of a disease. Studying the etiology of the patient’s condition
helps us find the factors with which produce or predispose toward a certain disease or disorder.
Predisposing
FactorsPresence Justification Rationale
Age Present Patient B is
57 years old.
The chances of having a stroke go up with age.
Twothirds of all strokes happen to people who
are over age
65. Stroke risk doubles every 10 years past age
55. The risk of stroke increases
with age, each ten years double the stroke
risk after the age of 55. At least 66 percent of all
people with stroke were aged 65 or more.
Source: https://www.myhealth.va.gov/mhv-
portal-web/ShowBinary/BEA%20Repository/
pdf/Stroke_Risk_Check.pdf
Gender Present Patient B is
Male.
Stroke is more common in men than women.
Almost one in four men and nearly one in five
women can expect to have a stroke if they live
to their 85th year.
46 | P a g e
Source: http://www.stroke.org/site/PageServer?
pagename=RISK
Hereditary Present Patient B
Mom and
Dad have
Hypertension
.
A very great number of association studies have
been performed in order to examine the possible
implication of candidate genes due to their
known or supposed functions, but very few
genetic variants have been associated with an
increased risk of CVA, this increase being
modest moreover. Quite recently an approach
combining genetic linkage analysis and a
haplotypic association study has allowed the
localisation and identification of a new gene,
phosphodiesterase 4D, implicated in ischaemic
CVA, and the localisation on chromosome 7 of
a gene implicated in the occurrence of cerebral
aneurysms, thus raising new hopes in this
multifactorial form. Although actual risk varies,
people with a family history of stroke is at risk
for stroke themselves.
Source:
http://www.ncbi.nlm.nih.gov/pubmed/14694787
47 | P a g e
Race Absent Patient B is
an Asian, a
Filipino.
Black and Hispanic Americans have a higher
risk than people of other races. Compared with
whites, young black Americans, both women
and men have a risk of 2 to 3 times more likely
to make a stroke and die from this cause. People
of Asian and African-Caribbean ethinicity.11
The prevalence of stroke is 40-70% higher
among African-Caribbean and South Asian men
than in the general population.
Source: http://www.doctortipster.com/3062-
stroke-cva-causes-risk-factors-symptoms-and-
treatment.html#ixzz2F8ZZ7z6l
Prior stroke
attack
Present Patient B had
a past history
of stroke last
November
24, 2012
Transient Ischemic Attacks, also called TIAs or
ministrokes, are brief episodes of stroke
symptoms that usually last for only a few
minutes. Symptoms may include weakness,
numbness, speech changes, and blindness.
Unlike stroke, TIAs do not result in permanent
brain damage. More than one- third of all people
who experience TIAs will go on to have a
48 | P a g e
stroke. If already had a stroke, it may be up to
10 times more likely to have another.
Source: https://www.myhealth.va.gov/mhv-
portal-web/ShowBinary/BEA%20Repository/
pdf/Stroke_Risk_Check.pdf
Precipitating
FactorsPresence Justification Rationale
Hypertension Present Patient B BP
upon admission
is
280/170mmHg
Uncontrolled high blood pressure increases a
person's stroke risk by four to six times. Over
time, hypertension leads to atherosclerosis and
hardening of the large arteries. This, in turn, can
lead to blockage of small blood vessels in the
brain. High blood pressure can also lead to
weakening of the blood vessels in the brain,
causing them to balloon and burst. The risk of
stroke is directly related to how high the blood
pressure is.
Source: Kozier and Erb’s Fundamentals of
nursing, 8th edition 2008 by: Berman, Aubrey,
Synder, Shirlee, Kozier, Barbara & Erb, Glenora
Diabetes Present Patient B sugar Individuals with insulin resistance or diabetes in
49 | P a g e
Mellitus level shows and
his taking RI
during
admission.
combination with one or more of these risk
factors are more likely to fall victim to heart
disease or stroke.
Source: Kozier and Erb’s Fundamentals of
nursing, 8th edition 2008 by: Berman, Aubrey,
Synder, Shirlee, Kozier, Barbara & Erb, Glenora
Elevated bad
blood
cholesterol
levels (LDL)
Present Patient B level
of cholesterol.
Patients with diabetes often have
unhealthy cholesterol levels including high LDL
("bad") cholesterol, low HDL ("good")
cholesterol, and high triglycerides. This triad of
poor lipid counts often occurs in patients with
premature coronary heart disease. It is also
characteristic of a lipid disorder associated with
insulin resistance called atherogenic
dyslipidemia, or diabetic dyslipidemia in those
patients with diabetes. Learn more
aboutcholesterol abnormalities as they relate to
diabetes.
Source:
http://www.heart.org/HEARTORG/Conditions/D
iabetes/WhyDiabetesMatters/Cardiovascular-
50 | P a g e
Disease-Diabetes_UCM_313865_Article.jsp
Coronary
artery disease
Absent Patient B
diagnosed as
Cerebrovascula
r bleed
capsuloganglio
nic
hypertension II
That can lead to a heart attack and a stroke and
other heart disease such as atrial fibrillation,
endocarditis, heart valve disease,
cardiomyopathy, patent foramen ovale
Source: http://www.doctortipster.com/3062-
stroke-cva-causes-risk-factors-symptoms-and-
treatment.html#ixzz2F8mmAFwh
Smoking Present Patient B
smokes 2-3
sticks
occasionally.
Smoking doubles your risk for stroke. It speeds
up hardening of the arteries, increases the chance
for blood clots to form, and raises your blood
pressure. The good news is that if you quit
smoking today, your stroke risk from this factor
may decrease significantly.
Source: https://www.myhealth.va.gov/mhv-
portal-web/ShowBinary/BEA%20Repository/
pdf/Stroke_Risk_Check.pdf
Alcohol intake Present Patient B drink
such as beer
with his friend
after the make-
ups event.
Studies show that drinking alcohol in moderation
—up to two drinks per day—may reduce your
risk for stroke by almost half. However, drinking
more than two drinks per day may increase your
risk for stroke by as much as three times.
51 | P a g e
Because alcohol is a drug which can interact
with medication you are taking, we recommend
that you discuss alcohol use with your provider.
Drinking alcohol can lead to other health and
lifestyle problems
Source: Kozier and Erb’s Fundamentals of
nursing, 8th edition 2008 by: Berman, Aubrey,
Synder, Shirlee, Kozier, Barbara & Erb, Glenora
Physical
inactivity
Absent “Patient B
owned a parlor
shop and
“karinderya”,
early in the
morning he
goes to the
market and
cooks for his
“karinderya”.
Physical inactivity is another modifiable major
risk factor for insulin resistance and
cardiovascular disease. Exercising and losing
weight can prevent or delay the onset of type 2
diabetes, reduce blood pressure and help reduce
the risk for heart attack and stroke. It's likely that
any type of physical activity—whether sports,
household work, gardening or work-related
physical activity—is similarly beneficial.
Source: Kozier and Erb’s Fundamentals of
nursing, 8th edition 2008 by: Berman, Aubrey,
Synder, Shirlee, Kozier, Barbara & Erb, Glenora
Obesity Absent Patient B’s Excess weight puts a strain on the entire
52 | P a g e
BMI is 19.46-
Normal
Wight =53kg
Height= 165cm
circulatory system. It also makes people more
likely to have other stroke risk factors such as
high cholesterol, high blood pressure, and
diabetes. Excess weight can be reduced with
changes in diet and exercise.
Source: http://www.heart.org/HEARTORG/
X- SYMPTOMATOLOGY
The symtomatology of the patient’s condition is made to determine the presence or absence of
the signs and symptoms common to a disease.
Symptoms Present/ Rationale Justification
53 | P a g e
Absent
Unilateral Limb
weakness
Present Patient B experienced paralysis
in his right side since the
affected area is in his left brain.
Affected side exhibits
numbness and weakness.
Muscles are contracted and
tense, so movement is
difficulty. The side of the
body opposite of the cerebral
infarct is affected because as
fibers cross over right after
passing the brain.
Source: Tortora and
Derrickson, 9th edition.
Difficulty in
speech or
comprehending
Present Patient B during interview has
difficulty in enunciating words.
Damage to one or more of
the language areas of the
brain. Many times, the cause
of the brain injury is a stroke.
A stroke occurs when blood
is unable to reach a part of
the brain. Brain cells die
when they do not receive
their normal supply of blood,
which carries oxygen and
54 | P a g e
important nutrients.
Source:
http://www.strokecenter.org/
patients/caregiver-and-
patient-resources/aphasia-
information/
Difficulty in
seeing in one or
both eyes
Present Patient B affected body area is
in his right, patient B cannot
see clearly/ blurred vision in
his right eye.
Blindness in half of the
visual field or both eyes is a
common occurrence with
CVA. It happens because of
the disruption of optic nerve.
Source: Tortora and
Derrickson, 9th edition.
Loss of body
coordination, loss
of balance
Present Patient B cannot walk properly,
he used wheelchair.
It will happen because of the
damage of cerebellum.
Cerebellum is the one
responsible for the initiation
and control of movements of
extremities in the brain stem.
Source: Williams and
Hopper 2007
55 | P a g e
Severe headache Present Patient experienced headache
sometimes as he stated.
It occurs due to increased
intracranial pressure.
Headache may be associated
with the displacement of
pain-sensitive blood vessels
and cranial structures when
blood enters the area
surrounding the brain.
Source: Williams and
Hopper 2007
Nausea and
Vomiting
Present Patient experienced nausea and
vomiting as he stated.
Symptoms From Blockage in
the Basilar Artery. The other
major site of trouble, the
basilar artery, is formed at
the base of the skull from the
vertebral arteries, which run
up along the spine and join at
the back of the head. When
stroke or TIAs occur here,
both hemispheres of the
brain may be affected so that
symptoms occur on both
56 | P a g e
sides of the body.
Source:
http://health.nytimes.com/he
alth/guides/disease/stroke/pri
nt.html
drowsiness Present Stroke could have damaged
the parts of the brain
involved in sleep/wake
cycles.
Source:
http://www.caring.gov/
Unequal pupil
size
Present Due to increased in
intracranial pressure or
damage in cranial nerves III,
IV and VI.
Source:
http://www.nlm.nih.gov/medl
ineplus/ency/article/003314.
htm
57 | P a g e
58 | P a g e
XI- PATHOPHYSIOLOGY
Ow h
59 | P a g e
Predisposing Factors:
Age (+)
Race (-)
Hereditary (+)
Gender (+)
Prior stroke attack (+)
Precipitating Factors:
High Blood Pressure (+) Obesity (-)
Diabetes Mellitus (+) Alcoholism (+)
Cigarette Smoking (+)
High Fat High Sodium Diet (+)
Physical Inactivity (-)
Elevated bad blood cholesterol levels/LDL (+)
Decreased stretching ability of blood vessels
Increased blood viscosity
Increased Fluid Volume
Bleeding of blood vessels
Rupture of blood vessels
Increased Blood Pressure
Blood release into the brain tissue
Vasospasm limits blood flow
Clot formation
Decreased blood flow
o Severe
Headacheo Nausea
o Vomiting
60 | P a g e
Impaired nutrition and oxygenation of the brain
Bleed in the left capsuloganglionic area
No space for expansion; compression of brain tissue
Swelling of the brain
Pressure in the brain tissue
Cerebrovascular accident/
Stroke
Decreased cerebral perfusion
Brain tissue necrosis accurs at the affected area
Ischemia
o Weakness
o Drowsiness
o Unequal pupil
size
Difficultly speech or comprehending
o Loss of body
coordinationo Loss of
balance
Unilateral limb weakness
Difficulty seeing in one or both eyes
61 | P a g e
DEATH
IF NOT TREATED:
Continued inadequate
blood flow
Further tissue
compression
Severe paralysis
Respiratory arrest
Impaired brain function
IF TREATED:
Return to normal
perfusion
Improved Function
Treatment:
Medication
Physical
therapy/Rehabilitation
Lifestyle modification
Proper diet
BAD PROGNOSISGOOD PROGNOSIS
NARRATIVE PATHOPHYSIOLOGY
Cerebrovascular accident also known as stroke is a sudden impairment of cerebral
circulation in one or more blood vessels. The predisposing factors that affect the disease are age,
gender, genetics, chronic hypertension and prior stroke. Furthermore, it is precipitated by high
blood pressure, diabetes mellitus, low HDL, high blood cholesterol, Cigarette smoking,
Alcoholism, Physical inactivity and obesity. In the case of our patient, the predisposing factors
that affect the disease are hereditary, gender, and prior stroke attack. On the other hand the
predisposing factors are focused on hypertension, diabetes mellitus, alcoholism, cigarette
smoking and elevated LDL or high blood cholesterol level. These factors led to the inability of
the blood vessels to stretch and increase the blood viscosity. To compensate for this flow of
blood, there’s an increase in blood pressure. Just like in the case of our patient, his high blood
pressure in particular led to the rupture and bleeding of his blood vessel which causes severe
headache. These headaches are often followed by nausea and vomiting. As a result, blood release
around the cells. In our patient’s case, the bleeding occurred in the capsuloganglionic area. This
area is one of the most common sites of hypertensive bleeds. The release of blood leads to the
swelling of the brain. The swelling causes pressure in the brain tissues. Since the skull doesn’t
allow room for expansion, the tissues are compressed and this compression leads to lack of
nutrition and oxygen to the brain. This leads to the inability of the brain to store glucose and
oxygen. Therefore, Brain tissue necrosis happens which leads to decrease cerebral perfusion,
which then leads to cerebrovascuar accident. Furthermore, as blood is released, it irritates the
blood vessels and meninges because blood is a noxious agent. Another effect of the bleeding is
the constriction of the blood vessel; this is to limit blood loss. As a result to the vasospasm, blood
62 | P a g e
is limited and clotting follow. Apparently, this leads to the decrease flow of oxygenated blood in
the brain. This is when cerebrovascular accident occurs. This then shows unilateral limb
weakness, difficulty in speech or comprehending, difficulty in seeing in one or both eyes, loss of
body coordination and loss of balance.
If treatment such as proper medication is followed and rehabilitation is done, then there
would be a return of normal perfusion and appropriate blood flow is restored. Also, physical
therapies and rehabilitations help prevent further complications. If not treated, there would be
inadequate blood flow and further tissue compression. This leads to more severe paralysis and
respiratory arrest later on may lead to death.
63 | P a g e
XII- DOCTOR’S ORDER
Date/Time Doctor’s Order Rationale Remarks
11/24/12 • Please admit
under white
service to
IMCU level 3
The patient is
to be admitted
to Intermediate
Medical Care
Unit level 3 for
further
monitoring and
proper
management.
DONE
• Secure consent
to care
Client or
guardian’s
signed consent
necessary for
medical care
and
procedures.
This is to
avoid any
unauthorized
procedure and
DONE
64 | P a g e
to protect the
health team
from any legal
issues.
• Insert NGT FR
14 (keep end
closed)
If patient has
difficulty
eating or
drinking after
48 hours,
alternate
feeding routes
are used, such
as tube
feeding.
DONE
FR 16 given
• OTF of 1800
Kcal/day 6
divided
feedings.
If patient has
difficulty
eating or
drinking after
48 hours,
alternate
feeding routes
are used, such
DONE
65 | P a g e
as tube
feeding.
• V/S q hourly Monitoring of
vital signs
every hour is
done to serve
as a baseline
data for further
interventions
and to monitor
any
unusualities
the patient
may
exemplify.
DONE
Dx:
• CBC, Platelet
Count
Complete
blood count
with platelet
count is
ordered to
check the
hematologic
status of the
DONE
66 | P a g e
patient
regarding the
cause of CVA
hematologic
status of the
patient and for
signs of
thrombosis.
• Blood Typing Blood typing:
Blood typing
is a method to
tell what
specific type
of blood you
have. What
type you have
depends on
whether or not
there are
certain
proteins, called
antigens, on
your red blood
DONE
67 | P a g e
cells.
• Prothrombin
time with INR,
APTT
Prothrombin
time (PT) is a
blood test that
measures how
long it takes
blood to clot.
A prothrombin
time test can
be used to
check for
bleeding
problems. PT
is also used to
check whether
medicine to
prevent blood
clots is
working.
INR
(international
DONE
68 | P a g e
normalized
ratio) stands
for a way of
standardizing
the results of
prothrombin
time tests, no
matter the
testing
method.
• Cranial CT
scan plain-
done
Cranial
Computed
Tomography
Scan done to
rule out
evidence of
hemorrhagic
stroke.
DONE
Left
Capsuloganglionic
Bleed in 20cc
• Chest X-ray
Posterior-
Anterior view
Chest X-Ray
done to rule
out cardiac
DONE
69 | P a g e
origin as the
source of
embolus.
• ECG 12 leads
with long lead
II
1. ECG- 12
Leads done to
assess
dysfunctional
heart rate due
to impaired
autonomic
control from
the brain
caused by
infarct.
Specifically, it
is to rule out
atrial
fibrillation.
DONE
• serum
creatinine,
sodium,
potassium
2. Creatine test
done to assess
severity of loss
of creatine
which would
DONE
70 | P a g e
adversely
affect the
communicatio
n between the
peripheral and
central nervous
system with
the muscles.
3.Sodium testing is
used to detect
abnormal
concentrations
of sodium. It
may be
ordered to
determine if a
disease or
condition
involving the
brain, lungs,
liver, heart,
kidney,
71 | P a g e
thyroid,
or adrenal
glands is
causing or
being
exacerbated by
a sodium
deficiency or
excess.
4. Potassium
testing is used
to detect
concentrations
that are too
high
(hyperkalemia)
or too low
(hypokalemia)
• FBS, lipid
profile
1. FBS done to
measure
glucose levels
in the blood.
NOT DONE
72 | P a g e
Severe
hyperglycemia
can lead to
poor outcomes
and reduced
perfusion of
the brain
should
thrombolysis
occur.
2. Lipid Profile
done to assess
the cholesterol
blood level in
the client in
order to assess
for the
possibility of
plaque
development
in the arteries
which may
73 | P a g e
cause CVA.
• CBG now 1. To monitor
fluctuation of
glucose levels.
Capillary
blood glucose
testing is used
as a
monitoring
tool giving a
guide to blood
glucose levels
at a specific
moment in
time. This is
done because
hyperglycaemi
c levels are
associated with
worsening
stroke
condition.
DONE
74 | P a g e
• Consume
Nicardipine
drip:
Nicardipine
10mg + 90cc
D5W to run @
5mg/kg/hr
q15mins until
MAP of 110-
120 is
achieved as
side drip.
2. Nicardipine
injections are
used for short-
term treatment
of blood
pressure when
oral
medications
are not
possible or
desirable.
Paired with
D5W for fluid
replacement
and parenteral
access
of medications
and for the BP
not to decrease
abruptly and
for it to be
regulated
DONE
75 | P a g e
properly.
• D5W 500cc
to run at KVO
rate (main
line)
3. Isotonic
solution
indicated for
rehydration,
keeps the body
from using up
protein and
muscle mass
by giving it
carbohydrates
and can
decrease
sodium and
potassium
levels.For fluid
replacement
and parenteral
access
of medications
.
DONE
Medications:
• Mannitol 20%
4. Mannitol
reduces an
DONE
76 | P a g e
150cc q6 as
bolus
increase in
intracranial
pressure,
improves
cerebral
metabolism
and
oxygenation in
patients after
brain injury.
• Citicoline
1gram IVTT
q12
5. Citicoline is a
naturally
occurring brain
chemical that
is important
for brain
function. It is
given to
improve
impaired
functioning of
the brain for
victims with
DONE
77 | P a g e
cerebral
vascular
accidents.
• Senna Conc. 2
tabs OD @HS
6. Promotes
incorporation
of water into
stool resulting
in softer fecal
mass and
relieving
constipation.
DONE
• Refer to
Neurosurgery
for STAT
evaluation and
co-mgt
7. Refered to
Neurosurgery
to assess
condition and
possible
treatment for
the patient.
DONE
• Moderate high
back rest
8. Patient’s head
is elevated to
reduce cerebral
edema by
improving
DONE
78 | P a g e
venous
drainage.
• Complete Bed
Rest w/o
Bathroom
Privilege
9. CVA patients
have body
weakness and
have to
recuperate and
prevent from
any possible
injuries that
may occur.
DONE
• Retain Foley
catheter F16
attached to
urobag
10. Foley Catheter
is attached due
to the order of
complete bed
rest w/o
bathroom
privilege.
DONE
• I&0 q shift 11. Monitoring the
intake and
output of
patient allows
the nurse to
DONE
79 | P a g e
compare the
amount of
fluid the
patient takes in
and out.
• Refer
accordingly
12. To report any
unusualities
that may
develop into
complications
11/24/12
GCS 9-10 E3-4 V1
M5
Isocoric
Aphasic. Spontaneous
purposeful
movements
CT Scan
Left
Capsuloganglionic
Bleed in 20cc
Neurosurgery notes:
• Patient seen
& examined
13. Neurosurgery
assessed and
evaluated the
medical
condition of
the patient to
provide
appropriate
care and
treatment.
DONE
• History
reviewed
14. Assessed for
any related
conditions or
DONE
80 | P a g e
(-)midline shift
factors that
may have
affected the
patient.
• Scan verified 15. Reviewed scan
results to
evaluate
condition of
the patient.
DONE
• CO-manage
patient
16. Further
continue
management
and treatments
to patient.
DONE
• Shift IVF to
PNSS 1L @
140cc/hr while
on mannitol
17. Mannitol will
crystallize with
D5W that’s
why it is
shifted to
PNSS an
isotonic table
salt used to
give IV fluids
NOT DONE
81 | P a g e
to the patients
shifting from
salt and water
deprivation.
• Atorvastatin
80mg 1Tab
OD
18. Atorvastatin is
an oral drug
that lowers the
level of
cholesterol in
the blood. It
his given to
stroke patients
to prevent the
continued
formation of
plaques.
DONE
• Increase
Citicoline to
1g IVTT q8
19. Citicoline is a
naturally
occurring brain
chemical that
is important
for brain
function. It is
DONE
82 | P a g e
given to
improve
impaired
functioning of
the brain for
victims with
cerebral
vascular
accidents.
• Neuro Aid 4
caps TID
20. NeuroAiD™ is
a natural oral
treatment
dedicated
to stroke
recovery and s
troke
rehabilitation.
DONE
• Cerebrolysin 1
amp IVTT q8
21. Treatment of
disturbances of
concentration
and memory
and sequels of
stroke
DONE
83 | P a g e
(ischaemic and
haemorrhagic)
• Will refer to
service
consultant
22. To report any
unusualities
that may
develop into
complications
DONE
• Thank you for
this referral
23. Your
welcome!
11-25-12
2:00 AM
• 1 Citicoline 1
gm IVTT q8
24. Same rationale
as mentioned
above.
NOT DONE
• Shift IVF to
PNSS
1L@100cc/hr
25. PNSS an
isotonic table
salt used to
give IV fluids
to the patients
shifting from
salt and water
deprivation.
NOT DONE
84 | P a g e
• May continue
other meds
ordered by
neuro surgery
26. Other
medications
are still to be
continued to
aid health
promotion and
should be
given on time
as needed.
DONE
Dx:
• FBS, Lipid
profile,
CKMB, Trop I
27. Same with
diagnostic
rationale above
NOT DONE
• APTT, PT
with INR
28. Same with
diagnostic
rationale above
DONE
• Urinalysis An indicator of
health and
disease, it is
helpful in the
NOT DONE
85 | P a g e
detection of
renal or
metabolic
disorders. It is
an aid in
diagnosing and
following the
course of
treatment in
diseases of the
kidney and
urinary
system.
• Increase
mannitol to
150cc q6 hrs x
5 days then re-
assess
To relieve
hypertension
and to reduce
intracranial or
intraocular
pressure
DONE
• Start
Omeprazole
40mg 1 Cap
OD
Treatment of
active
duodenal
ulcer.
DONE
86 | P a g e
• Irbesartan
300mg 1 Tab
now then OD
in AM
1. Treatment of
hypertension
alone or in
combination
with other
antihypertensi
ves.
DONE
• Amlodipine
10mg 1 Tab
now then OD
at HS
2. Management
of
hypertension
DONE
• Paracetamol 1
tab q 4hrs
PRN for Temp
greater than or
equal to 37
degrees
celscius
3. Decreases
fever by a
hypothalamic
effect leading
to sweating an
d vasodilation
DONE
• CBG 4. To monitor DONE
87 | P a g e
monitoring q6
pre-meals (5-
11-5-11)
fluctuation of
glucose levels.
Capillary
blood glucose
testing is used
as a
monitoring
tool giving a
guide to blood
glucose levels
at a specific
moment in
time. This is
done because
hyperglycaemi
c levels are
associated with
worsening
stroke
condition.
• RI 10 “u” SQ
q6
5. Insulin is
prescribed for
because there
DONE
88 | P a g e
is an episode
of an increase
in blood sugar.
• Standing
Order 5 “u”
IVTT for
CBG
>140g/dl
6. Insulin is
prescribed for
because there
is an episode
of an increase
in blood sugar.
DONE
• Standing order
D50W 25cc
IVTT for
CBG< or = to
80mg/dl_
D50W 50cc
IVTT for
CBG< or =
70mg/dl
NOT DONE
• Repeat CBG q
15 mins until
>100mg/dl
7. Same with
diagnostic
rationale above
ordered for
DONE
89 | P a g e
close
monitoring of
sugar level.
• monitor
electrolytes in
normal levels
8. Assess if there
are electrolyte
imbalances
present.
DONE
• Aggressive
TSB
9. TSB done to
reduce fever.
DONE
• maintain
Systolic BP=
140-160
10. Maintaining
BP will ensure
safety on not
having severe
hypertention
and reduce risk
of hypotension
due to drugs
administered.
DONE
• Refer 11. To report any
90 | P a g e
accordingly unusualities
that may
develop into
complications
6:00 AM
Cxr: LV cardiomegaly
considered
unremarkable
pulmonary findings
• Transfer
patient to
ICU2 – L3
12. Patient to be
transferred to
intensive care
unit 2 – level 3
for close
monitoring and
provide proper
treatment.
DONE
• Continue all
meds
To maintain
the
pharmacologic
al effect of
medications as
indicated.
DONE
• Attach all labs
to chart
All labs done
by patient
referred to
NOD and
NOT DONE
91 | P a g e
attach to chart.
Refer
accordingly
To report any
unusualities
that may
develop into
complications
11-26-12
3:00 AM
BP: 170/100 mmHg
Telephone Order of
Dr. Mantos to
Charmaine Miranda
R.N:
• Start
Hydrolazine
drip with D5W
500cc + 4
amps
Hydralazine to
run at 5
ugtts/min with
increments of
5 ugtts/min
every 20 mins
with
1. Management
of moderate to
severe
hypertension.
Paired with
D5W for fluid
replacement
and parenteral
access
of medications
and for the BP
not to decrease
abruptly and
for it to be
regulated
properly.
DONE
92 | P a g e
maximum
dose of 30
ugtts/min
• Maintain MAP
at 110 mmHg
2. Mean arterial
pressure is
considered to
be
the perfusion
pressure seen
by organs in
the body.
DONE
1:40 PM
GCS 10
E3 M6 V1
• Aphasic
• Diagnostic:
To secure
Cranial CT
scan
follow up
chest xray
result
ABG
USD of KUB
+ Prostate
1. CT Scan:
Rationale of
Diagnostics
stated earlier
Chest X-ray
Rationale of
Diagnostics
stated earlier
ABG & Blood
Typing
DONE
93 | P a g e
secure
Blood typing ABG:
Blood gases
are drawn to
determine
acid-base
imbalances.
USD of the
KUB +
Prostate:
Ultrasound
may be used to
diagnose the
presence of
urinary
obstruction, ki
dney
stones and also
to assess the
blood flow into
the kidneys.
94 | P a g e
And any
changes or
enlargement of
the prostate
gland.
Blood typing:
Rationale of
Diagnostics
stated earlier
• Continue meds To maintain
the
pharmacologic
al effect of
medications as
indicated.
DONE
• Metroprolol
100mg PO
BID
Treatment of
hemodynamica
lly stable acute
myocardial
DONE
95 | P a g e
infarction,
angina
pectoris,
hypertenstion.
• Captopril 25
mg
SubLingual if
SBP>180mm
Hg
Treatment of
hypertension
DONE
• Kalium Durule
1TAB PO
Days TID
Prevention and
correction of
potassium
deficiency
DONE
• IVF PNSS
120cc/hr
Same rationale
as mentioned
above
DONE
• I&O
monitoring
Same rationale
as mentioned
above
DONE
• Continue CBG Same rationale DONE
96 | P a g e
monitoring q6 as mentioned
above
Refer
4:00 PM
GCS 9-10
E3-4 V1 M5
Receptive Aplasia
Neurosurgery notes
• May have
gelatin diet &
sips of water
PO
Soft diet is
ordered to start
normalization
diet and
exercise
swallowing.
DONE
• Progress to
oatmeal then
porridge once
tolerated
Soft diet is
ordered to start
normalization
diet and
exercise
swallowing.
DONE
• Suggest NGT
removal once
tolerated
NGT removal
is ordered once
patient can eat
and well
tolerated
without
problems.
NOT DONE
97 | P a g e
• Cont
Hydrolazine
Same rationale
as mentioned
above
DONE
• Cont meds To maintain
the
pharmacologic
al effect of
medications as
indicated.
DONE
• Refer
10:00 AM • For
compliance to
meds
Same rationale
as mentioned
above
DONE
• Turn patient
side to side
CVA puts the
client in a
bedridden
position and
thus prone to
the
development
DONE
98 | P a g e
of bedsores. To
prevent
formation of
bed sores,
change of
positioning of
at least every
two hours is
done to relieve
pressure from
staying in one
area.
• Moderate
High Back
Rest
Patient’s head
is elevated to
reduce cerebral
edema by
improving
venous
drainage.
DONE
• Refer to
DSWD, for
family tracing
To trace
location of
family and
contact for
DONE
99 | P a g e
informations.
• Refer
accordingly
2:00 PM Rounds w/ Dr. Del Rosario
• Hold
Hydralazine
Maintained BP
or desired level
is assured of
preventing
hypertension.
DONE
• Cont General
liquids
General liquids
help in
rehydration.
DONE
• Amlodipine
BID
Same rationale
as mentioned
above
DONE
• Cont. other
meds
To maintain
the
pharmacologic
al effect of
medications as
indicated.
DONE
100 | P a g e
• Cont. trail
feeding
Trail feeding
done for
progression
diet to be
tolerated and
enhance
swallowing
reflex to
prevent
aspiration.
DONE
• Refer
140/100 mmHg
70 bpm
20 cpm
37 C
E4 V2 M6
IM Neuro
• For repeat
cranial CT
scan
Same
diagnostic
rationale as
mentioned
above
DONE
• May remove
NGT
Same
diagnostic
rationale as
mentioned
DONE
101 | P a g e
GCS 12 above
• Cont. meds To maintain
the
pharmacologic
al effect of
medications as
indicated.
DONE
• Cont. CBG
monitoring
Same
diagnostic
rationale as
mentioned
above
DONE
11/28/12
10:30 AM
• Suggest to
transfer patient
under
neurosurgery
• Service if
ok with IM
Patient to be
transferred to
neurosurgery
ward for
further
assessment,
monitoring and
treatment.
DONE
• May transfer
patient to
Neuro L3
DONE
102 | P a g e
• Will co
manage pt
DONE
• Refer
11:00 AM Trans out to neuro
ward
Meds.
• Amlodipine
10mg 1 Tab
BID
Same
diagnostic
rationale as
mentioned
above
DONE
• Metroprolol
100mg 1 Tab
BID
Same
diagnostic
rationale as
mentioned
above
DONE
• Kalium Durule
TID x 3 days
Same
diagnostic
rationale as
mentioned
DONE
103 | P a g e
above
• Irbesartan
300mg 1 Tab
OD
Same
diagnostic
rationale as
mentioned
above
DONE
• Mannitol
100cc IVTT
q8 hrs
Same
diagnostic
rationale as
mentioned
above
DONE
• Citicoline
500mg 2 caps
TID
Same
diagnostic
rationale as
mentioned
above
DONE
• Senna
Concentrate 2
tabs OD @ HS
Same
diagnostic
rationale as
mentioned
above
DONE
Atrovastatin
80mg 1 Tab
Same
diagnostic
DONE
104 | P a g e
OD @ HS rationale as
mentioned
above
11/29/12 • Cont. meds To maintain
the
pharmacologic
al effect of
medications as
indicated.
DONE
• Progression
diet
For the
stomach to
adjust and
assess if diet
can be
tolerated to
reduce risk of
aspiration.
DONE
• Refer To report any
unusualities
that may
develop into
complications
11/30/12 • Cont. meds To maintain DONE
105 | P a g e
the
pharmacologic
al effect of
medications as
indicated.
Refer To report any
unusualities
that may
develop into
complications
12/1/12 • Mannitol to
50cc IVTT x 3
doses
Same
diagnostic
rationale as
mentioned
above
DONE
Resume Foley
catheter
Distention in
the bladder/
incontinence
resulting to
reattachment
of Foley
Catheter.
DONE
• Full Body bath 1. For hygienic DONE
106 | P a g e
purposes to
reduce risk of
infection
• Refer To report any
unusualities
that may
develop into
complications
10:00 AM Cleared from neurosurgery
• MGH
neurosurgery-
wise
May be
discharged
from the ward
and may go
home.
• IM – neuro for
final
disposition
• Refer To report any
unusualities
that may
develop into
107 | P a g e
complications
12/2/12 DIET: Low Salt Low
Fat, Low Caffeine
diet
Low salt is
advised to
prevent
hypertension
and
constriction of
blood vessels.
Low fat diet
advised to
prevent further
formation of
plaques
leading to
arthrosclerosis.
DONE
Home meds:
• Senna
Concentrate 2
Tabs OD @
HS
Same
diagnostic
rationale as
mentioned
above
To Comply
108 | P a g e
• Atorvastatin
40mg 1 Tab
OD @ HS
Same
diagnostic
rationale as
mentioned
above
To Comply
• Irbesortan
300mg 1 Tab
OD
Same
diagnostic
rationale as
mentioned
above
To Comply
• Amlodipine
10mg 1 Tab
BID
Same
diagnostic
rationale as
mentioned
above
To Comply
Citicoline
500mg 1 Tab
TID x 1 month
Same
diagnostic
rationale as
mentioned
above
To Comply
109 | P a g e
• Metroprolol
100mg 1 Tab
BID
Same
diagnostic
rationale as
mentioned
above
To Comply
Follow up
check up after
1 week
Check-up must
be done to
reassess and
evaluate
condition for
improvement
or
reoccurrence.
To Comply
12/3/12 • MGH still in Still waiting
for billing
process.
DONE
• Cont meds Medications
are to be
continued to
aid health
promotion.
DONE
110 | P a g e
111 | P a g e
Date and Time Diagnostic Test/ Normal Range
Result Purpose Clinical Significance Nursing Responsibility
Date and Time received:11-25-1207:33 AM
Date/Time Reported:11-25-1208:35 AM
Date/Time released:11-25-1217:23 PM
Hemoglobin135-175
Hematocrit0.40-0.52
96.0 g/L L
0.29 L
Hemoglobin test measures the amount of hemoglobin in blood and is a good measure of the blood's ability to carry oxygen throughout the body.-used to determine if patient need blood transfusion.
-measured on a person to determine the extent of anemia.
-the test to show anemia or present of polycythemia.
Below the Normal Range
Below the Normal Range
1. Explain the procedure and purpose of the test to the patient.R: To gain cooperation from the patient.
2. Tell the patient that no fasting is required.R: Food intake before the test has no colossal effect on the result.
3. Assess the hydration status of the client.R: because hydration may alter results.
4. Ensure that the blood is not taken from the hand or arm that has an intravenous line.R: Hemodilution with intravenous fluids causes a false decrease in the value
112 | P a g e
XIII- DIAGNOSTIC AND LABORATORY TEST
RBC Count 4.20-6.10
WBC Count 5.0-10.0
3.53x10^6/uL L
8.34x10^3/uL
-Used to determine anemia and hemorrhage.-This test may also be used to help diagnose and/or monitor any number of diseases that affect the production or lifespan of the red blood cells.
-used to determine the presence of other diseases that affect WBCs such as allergies, leukemia or immune disorders.-test is used to test the monitor/function of bone marrow.
Below the Normal Range
Within the normal range
5. Assess the puncture site for signs and symptoms of bleeding or bruising of the skin.R: It is essential for the nurse to apply pressure by using sterile gauze at the site.
6. Assess the client for the presence of any physiologic factors that may affect the laboratory results.R: Physiologic factors may alter the results.
7. Immediately notify the physician if abnormal results are noted.R: To provide immediate care to the patient.
8. Observe and record any factor that may increase or decrease WBC count.
113 | P a g e
Date/Time Received:11-25-1205:02
Date/Time Reported:11-25-1208:24
Date/Time Released:11-25-12
Differential Count
Neutrophil 55-75
Lymphocytes 20-35
85 H
13L
-Help us detect the level of neutrophils in the body.-Tests are performed for routine health screenings or if a disease or toxicity is suspected.
-test measures the number of lymphocytes (a type of white blood cell) in blood- It is used to evaluate and manage disorders of the blood or the immune system.
Above the normal Range
Below the Normal Range
114 | P a g e
Monocytes 2-10
Eosinophil1-8
2
0L
-test measures the amount of monocytes in blood.
-This test is used to evaluate and manage blood disorders, certain problems with the immune system, and cancers, including monocytic leukemia
- This test may also be used to evaluate for the risk of complications after a heart attack.
-The test that counts the number of eosinophils.
- It is used to evaluate and manage allergic conditions, blood and infectious diseases as well as certain infections.
Within the Normal Range
Below the normal range
115 | P a g e
Basophil 0-1
Platelet Count150-400
0
243x10^3/uL
-Test measures the amount of basophils in blood.
-This test is used to help evaluate and manage treatments including certain allergic disorders, blood disorders, neoplastic disorders, and infections caused by parasites.
-A platelet count may be used to screen for or diagnose various diseases and conditions that affect the number of platelets in the blood.
Within the normal range
Within the normal range
High platelet count can lead to excessive, dangerous blood clotting if left untreated.
Low platelet count called thrombocytopenia refers to an abnormally low number of platelets, the particles in blood that help with clotting,
116 | P a g e
MCH( Mean Corpuscular Hemoglobin ) 25.70-32.20
MCHC( Mean Corpuscular
Hemoglobin Concentration )
32.30-36.50
27.3 pg
32.9 g/d
-Test that is carried out to diagnose the average amount of hemoglobin in the red blood cells.
-Used to test the level of hemoglobin in the blood.-a test that is carried out to test a person for anemia.
Within Normal Range
Within Normal Range
117 | P a g e
Date Released:11-25-12
Date Reported:11-25-12
Date Released:11-25-12
BLOOD CHEMISTRY
Blood Type
Blood Type Rh
AB
Positive
Importance why we need to know our blood type:
-The blood that should be transfused to you should match the blood type you have- to avoid mismatch in emergency cases.
-Each blood type is also grouped by its Rhesus factor, or Rh factor. Blood is either Rh positive (Rh+) or Rh negative (Rh-)
-Clean the needle site with alcohol.
-Put the needle into the vein. More than one needle stick may be needed.
-Attach a tube to the needle to fill it with blood.
-Remove the band from your arm when enough blood is collected.
-Put a gauze pad or cotton ball over the needle site as the needle is removed.
-Put pressure to the site and then a bandage.
-patient may feel nothing or may feel a quick sting or pinch.W
118 | P a g e
Potassium 3.5-5.5
Sodium136.00-155.00
3.36 mmoL/L L
139.50 mmoL/L
-To evaluate clinical signs of potassium excess or potassium depletion.
-to monitor renal function, acid base balance, and glucose metabolism
-To evaluate fluid electrolyte and acid-base balance and related neuromuscular, renal and adrenal functions.
-testing is used to detect abnormal concentrations of sodium, termed hyponatremia, and hypernatremia.
Below normal Range
Within normal Range
119 | P a g e
Creatinine53.00-115.00
314.30 mmoL/L H
-Measures the level of creatinine in the blood and urine .-used to diagnose impaired kidney function and to determine renal (kidney) damage.
Above the normal range
120 | P a g e
XIV- DRUG STUDY
Generic Name
Amlodipine Besylate
Brand Name (Norvasc)
Classification cardiovascular agent; calcium channel blocker; antihypertensive agent
Indications -Treatment of essential hypertension and angina
Dosage 10mg 1 tab BID
Action Inhibits calcium ions from entering the slow channels or select
voltagesensitive areas of vascular smooth muscle and myocardium
during depolarization.
Side Effects Rash, headache, dizziness and nausea
Adverse Effects CNS: Lightheadedness, fatigue, lethargy
CV: Peripheral edema, arhythmias
Dermatologic: Flushing
GI: Abdominal discomfort
Interactions 1. Drug-drug: possible increased serum levels and toxicity of
cyclosporine if taken concurrently.
Contraindications 1. Allergy to amlodipine
2. Hepatic or renal impairment
3. Sick sinus syndrome
4. Heart block
5. Sick sinus syndrome
6. Lactation
121 | P a g e
Nursing
Responsibilities
1. Orient self with the 10 rights of giving medication before
administering drug to the patient.
2. Assess patient for history of allergy to amlodipine, impaired
hepatic or renal function, sick sinus syndrome, heart block, or
CHF.
3. Physical assessment such as the skin lesion, color and edema.
4. Assess for adverse drug reactions; report irregular heartbeat,
swelling of the hands and feet, shortness of breath, pronounced
dizziness, and constipation.
5. Monitor patient’s blood pressure, pulse rate and cardiac rhythm
frequently.
6. Monitor for S&S of dose-related peripheral or facial edema that
may not be accompanied by weight gain; rarely, severe edema
may cause discontinuation of drug.
7. Instruct patient to take drug with meals if abdominal discomfort
occurs; advise on eating small, frequent meals for nausea and
vomiting.
8. Instruct patient to take oral form with meals to improve
absorption.
9. Instruct patient not to rise quickly off the bed.
10. Instruct patient to avoid sudden changes in position.
Source 1. http://two.xthost.info/wardclass2/Drug%20Study-
%20amlodipine.pdf
1. Nursing2009 Student Drug Handbook. 10th edition. Lippincott
Williams & Wilkins. Page 116-117
122 | P a g e
Generic Name:
metoprolol succinate/ metoprolol tartate
Brand name: Toprol-XL, Apo-Metoprolol, Betaloc , Lopressor, Norometoprol
Classification: Cardiovascular system drugs, antihypertensive, pregnancy risk category
C
Indication: 1. Hyperthension
2. Early intervention in acute MI
3. Agina pectoris
Dosage: 100 mg/tab ; BID
Action: Unknown. A selective beta blocker that selectively blocks beta
receptors; decreases cardiac output, peripheral resistance, and cardiac
oxygen consumption, and depresses rennin secretion.
Contraindication: 1. Contraindicated in patients hypersensitive to drug or other beta
blockers
2. Contraindicated in patients with sinus bradycardia, greater than
first-degree heart block, cardiogenic shock, or overt cardiac
failure when used to treat hypertension or agina. When used to
treat MI, drug is contraindicated in patients with heart rate less
than 45 beats/min, greater than first-degree heart block, PR
interval of 0.24 second or longer with first-degree heart block,
systolic blood pressure less than 100 mmHg or moderate to
severe cardiac failure.
3. Use cautiously in patients with heart failure, diabetes, or
respiratory or hepatic disease.
123 | P a g e
Side effects: Fatigue, dizziness, hypotension.
Adverse Effects: CNS: depression
CV: bradycardia, heart failure, AV block
GI: nausea, diarrhea
Respiratory: dyspnea
Skin: rash
Drug interactions: Drug-drug:
1. Amobarbital, aprobarbital, butabarbital,bulatbital,
mephobarbital, pentobarbital, phenobarbital, primidone,
secobarbital: May reduce metoprolol effect. May need to
increase beta-blocker dose.
2. Chlorpromazine: May decrease hepatic clearance. Watch for
greater beta-blocking effect.
3. Cimetidine: May increase beta-blocker effects. Consider another
H2 agonist or decrease dose of beta blocker.
4. Hydralazine: May increase levels and effects of both drugs.
Monitor patient closely. May need to adjust dosage.
Drug-herb:
1. Ma-huang: May decrease antihypertensive effects. Discourage
use together.
Drug-food:
2. Any food: May increase absorption. Encourage patient to take
drug with food.
Nursing
Responsibilities:
1. Always check patient’s apical pulse rate before giving drug. If
it’s slower than 60 beats/minute, withhold drug and call
prescriber immediately.
2. Monitor glucose level closely in diabetic patients because drug
masks common signs and symptoms of hypoglycemia.
124 | P a g e
3. Monitor blood pressure frequently; metoprolol masks common
signs and symptoms of shock.
4. Beta blocker may mask tachycardia caused by hyperthyroidism.
5. Store drug at room temperature and protect from light. Discard
solution if it’s discolored and contains particles.
6. Beta selectivity is lost at higher doses. Watch for peripheral side
effects.
7. Don’t confuse metoprolol with metaprotenol or metolazone.
1. Instruct patient to take drug exactly as prescribed and to take it
with meals.
2. Caution patient to avoid driving and other tasks requiring
mental alertness until response to therapy has been established.
3. Tell patient to alert prescriber if shortness of breath occurs.
4. Instruct patient not to stop drug suddenly but to notify prescriber
about unpleasant adverse reactions. Inform her that drug must
be withdrawn gradually over 1 or 2 weeks.
Sources: 5. Nursing2009 Student Drug Handbook. 10th edition. Lippincott
Williams & Wilkins. Page 837-839
6. Nursing2006 drug handbook. 26th edition. Lippincott Williams
& Wilkins. Page 301-302
7. http://nursingcrib.com/drug-guides/metoprolol-tartrate/.2007
125 | P a g e
Generic Name
Potassium Chloride
126 | P a g e
Brand Name Kalium Durule
Classification electrolytic and water balance agent
Indications Utilized for treatment of hypokalemia;
To prevent and treat potassium deficit secondary to diuretic or
corticosteroid therapy. Also indicated when potassium is depleted by
severe vomiting, diarrhea; intestinal drainage, fistulas, or
malabsorption; prolonged diuresis, diabetic acidosis. Effective in the
treatment of hypokalemic alkalosis (chloride, not the gluconate).
Dosage 100meq; 1 tab TID
Action Principal intracellular cation; essential for maintenance of intracellular
isotonicity, transmission of nerve impulses, contraction of cardiac,
skeletal, and smooth muscles, maintenance of normal kidney function,
and for enzyme activity. Plays a prominent role in both formation and
correction of imbalances in acid–base metabolism.
Side Effects Rash, GI bleeding, GI obstruction, GI ulceration, ECG (peaking of T
waves, loss of P waves depression of ST segment, prolongation of QTc
interval)
Adverse Effects GI: Nausea, vomiting, diarrhea, abdominal distension.
Body Whole: Pain, mental confusion, irritability, listlessness,
paresthesias of extremities, muscle weakness and heaviness of limbs,
difficulty in swallowing, flaccid paralysis.
Urogenital: Oliguria, anuria.
Hematologic: Hyperkalemia.
Respiratory: Respiratory distress.
127 | P a g e
CV: Hypotension, bradycardia; cardiac depression, arrhythmias, or
arrest; altered sensitivity to digitalis glycosides. ECG changes in
hyperkalemia: Tenting (peaking) of T wave (especially in right
precordial leads), lowering of R with deepening of S waves and
depression of RST; prolonged P-R interval, widened QRS complex,
decreased amplitude and disappearance of P waves, prolonged Q-T
interval, signs of right and left bundle block, deterioration of QRS
contour and finally ventricular fibrillation and death.
Interactions 8. Increased risk of hyperkalemia with potassium-sparring
diuretics, salt substitutes using potassium.
Contraindications 9. Allergy to amlodipine
10. Hepatic or renal impairment
11. Sick sinus syndrome
12. Heart block
13. Sick sinus syndrome
14. Lactation
Nursing
Responsibilities
15. Orient self with the 10 rights of giving medication before
administering drug to the patient
16. Give while patient is sitting up or standing (never in recumbent
position) to prevent drug–induced esophagitis. Some patients
find it difficult to swallow the large sized KCl tablet.
17. Do not crush or allow to chew any potassium salt tablets.
Observe to make sure patient does not suck tablet (oral
ulcerations have been reported if tablet is allowed to dissolve in
mouth).
18. Swallow whole tablet with a large glass of water or fruit juice (if
allowed) to wash drug down and to start esophageal peristalsis.
19. Lab test: Frequent serum electrolytes are warranted.
20. Monitor for and report signs of GI ulceration (esophageal or
epigastric pain or hematemesis).
21. Montitor I/O.
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22. Monitor PR and Cardiac rate. Irregular heartbeat is usually the
earliest clinical indication of hyperkalemia.
23. Be alert for potassium intoxication may result from any
therapeutic dosage, and the patient may be asymptomatic.
24. The risk of hyperkalemia with potassium supplement increases
(1) in older adults because of decremental changes in kidney
function associated with aging, (2) when dietary intake of
potassium suddenly increases, and (3) when kidney function is
significantly compromised.
Source 25. mims.com.ph
26. http://nurseslabs.com/kalium-durule-potassium-chloride-drug-
study/
27. Nursing2009 Student Drug Handbook. 10th edition. Lippincott
Williams & Wilkins. 963-964
Generic Name
Irbesartan
Brand Name Avapro
Classification Angiotensin II receptor antagonist (ARB), Antihypertensive
Indications Treatment of hypertension as monotherapy or in combination with
other antihypertensives. Slowing of the progression of kidney disease in
patients with hypertension and type 2 diabetes
Dosage 300mg 1 Tab; OD
Action Selectively blocks the binding of angiotensin II to specific tissue
129 | P a g e
receptors found in the vascular smooth muscle and adrenal gland; this
action blocks the vasoconstriction effect of the renin-angiotensin
system as well as the release of aldosterone, leading to decreased blood
pressure.
Side Effects Headache, dizziness, syncope, muscle weakness
Adverse Effects Hypotension, orthostatic hypotension
Rash, inflammation, urticaria, pruritus, alopecia, dry skin
Diarrhea, abdominal pain, nausea, constipation, dry mouth, dental pain
URI symptoms, cough, sinus disorders
Cancer in preclinical studies, back pain, fever, gout, fatigue
Interactions 28. Drug-drug: use caution with drugs metabolized by CYP2C9;
anticipated effects may altered
Contraindications 29. Contraindicated with hypersensitivity to irbesartan, pregnancy
(use during the second or third trimester can cause injury or
even death to the fetus), lactation.
30. Use cautiously with hepatic or renal dysfunction, hypovolemia.
Nursing
Responsibilities
31. Orient self with the 10 rights of giving medication before
administering drug to the patient
32. Assess patient for hypersensitivity to irbesartan, hepatic or renal
dysfunction and hypovolemia.
33. Physical assessment, assess the skin color, any lesions and
turgor.
34. Administer without regard to meals.
35. Monitor VS specially the BP.
36. Monitor patient I/O.
37. Monitor patients’ level of consciousness.
38. Assess for any sign of hypotension and dehydration.
39. Advised patient that he may experience side effects such as
dizziness, headache, nausea and vomiting
130 | P a g e
40. Advised to report immediately if fever, chills and dizziness
occur.
Source 41. http://nurse-sha.blogspot.com/2009/02/irbesartan-drug-
study.html
42. Nursing2009 Student Drug Handbook. 10th edition. Lippincott
Williams & Wilkins. 646-647
Generic Name:
mannitol
Brand name: Osmitrol, Sahar mannitol 20% solution for IV
Classification: Osmotic Diuretic; Pregnancy risk category
Indication: 1. Test dose for marked oliguria or suspected inadequate renal function
2. Oliguria
3. To prevent oligurioa or acute renal failure
4. To reduce intraocular or intracranial pressure
5. Diuretics in drug intoxication
6. Irrigating solution during transurethral resection of prostate gland
Dosage: 100cc
Action: Increases osmotic pressure of glumerular filtrate, inhibiting tubular
reabsorption of water electrolytes; drug elevates plasma osmolality,
increasing water flow into extracellular fluid.
131 | P a g e
Route Onset Peak Duration
I.V. 30-60 mins Unknown 3-8hr
Side effects: Diarrhea
Adverse Effects: CNS: dizziness, headache, blurred vision, seizures
CV: hypotension, hypertension, edema, tachycardia, chest pain
Dermatologic: urticaria, skin necrosis with infiltration
GI: nausea, anorexia, dry mouth, thirst
GU: dieresis, urine retention
Hematologic: fluid and electrolyte imbalances, hyponatremia
Respiratory: pulmonary congestion, rhinitis
Interactions: Drug-drug
1. Litium: may increase urinary excretion of lithium. Monitor litium
level closely
Contraindication: 2. Contraindicated in patients hypersensitive to drug
3. Contraindicated with anuria due to severe renal disease
4. Use cautiously with pulmonary congestion, active intracranial
bleeding, dehydration, renal disease, congestive heart failure,
pregnancy, lactation.
Nursing
Responsibilities:
1. Assess hypersensitivity of patient with the drug
1. Assess patient if he/she experienced severe or long-term kidney
disease, lung swelling or congestion, severe dehydration, bleeding in
your brain not caused by surgery, or if patient is unable to urinate
2. Do not expose solutions to low temperatures; crystallization may
occur. If crystals are seen, warm the bottle in a hot water bath, then
cool to body temperature before administering.
3. Make sure the infusion set contains a filter if giving concentrated
mannitol.
4. Monitor serum electrolytes periodically with prolonged therapy.
5. Store at room temperature between 56 and 86 degrees F (13 to 30
degrees C) away from light. Do not refrigerate or freeze.
6. Do not administer unless solution is clear and container is
132 | P a g e
undamaged. Discard unused portion. Do not administer Mannitol
25% if the Fliptop vial seal is not intact.
7. Do not share this medication with others. Laboratory and/or medical
tests (e.g., renal function, fluid/electrolytes balance) may be
performed to monitor patient progress.
8. If your dose is interrupted or stopped, consult doctor to establish a
new dosing schedule/IV rate.
9. Electrolyte-free mannitol solutions should not be given conjointly
with blood. If it is essential that blood be given simultaneously, at
least 20 mEq of sodium chloride should be added to each liter of
mannitol solution to avoid pseudoagglutination.
10. The cardiovascular status of the patient should be carefully evaluated
before rapidly administering mannitol since sudden expansion of the
extracellular fluid may lead to fulminating congestive heart failure.
Sources: 1. Nursing 2006 Drug Handbook, Lippincott Williams & Wilkins, page
855-857
1. http://www.emedicinehealth.com/drug-mannitol/article_em.htm
2. http://www.mims.com/USA/drug/info/Mannitol%20Injection%2c
%20Solution/?q=mannitol&type=full
Generic Name
Citicoline
Brand Name Nicholin, Somazine, 5′-Cytidine diphosphate choline
Classification Neurotonics, Nootropics
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Indications 1. Parkinson’s disease
2. Head injury
3. Cerebral vascular disease
4. Alzheimer’s disease
5. Cerebral surgery or acute cerebral disturbance
6. Disturbance of consciousness following brain surgery
7. Patients with acute, severe & progressive disturbance of
consciousness
8. Administration with hemostatics
9. Intracranial pressure relieving drugs or use measures to keep
body temp low.
Dosage 500mg 2 caps TID
Action 1. Citicoline seems to increase a brain chemical called
phosphatidylcholine. This brain chemical is important for brain
function. Citicoline might also decrease brain tissue damage
when the brain is injured.It is usually known that phospholipid,
especially lecithin, decreases following decline in brain activity
with cerebral trauma. Citicoline, which is a co-enzyme,
accelerates the biosynthesis of lecithin in the body.
2. This medication enhances the action of the brain stem ciliary
body especially the ascending ciliary body activating system,
which is closely related to consciousness, but does not exert
effort on the extrapyramidal system. Citicoline increases cerebral
blood flow and oxygen consumption of the brain and improves
cerebral circulation and metabolism.
3. Scientific research demonstrates that Citicoline consumption
promotes brain metabolism by enhancing the synthesis of acetyl-
choline, restoring phospholipid content in the brain and affecting
134 | P a g e
neuron membrane excitability and osmosis (by its effect on the
ATP-dependent sodium and potassium pump). When taken
orally, its two main components, Cytidine and Choline are
absorbed into the bloodstream.
4. Citicoline is also believed to protect nerve cells when in low
oxygen conditions. Citicoline may be used for nutritional support
in cerebral vascular disease, head trauma, stroke, and cognitive
disorders.
Side Effects 1. Body temperature elevation
2. Restlessness
3. Headaches
4. Nausea and vomiting
5. Diarrhea
6. Low or high blood pressure
7. Tachycardia
8. Sleeping troubles or insomnia
9. Blurred vision
10. Chest pains
Adverse Effects Fleeting and discrete hypotension effect, increased parasympathetic
affects, low blood pressure Itching or hives, swelling in face or hands,
chest tightness, tingling in mouth and throat
Interactions 11. Drug-drug: decreased the effectiveness of
(carbidopa/entacapone/levodopa)
Contraindications 12. Any allergy or hypersensitivity to the drug Hypertonia of the
parasympathetic nervous system Use cautiously for pregnancy
and lactation Conscious use for patient with renal and hepatic
damage
135 | P a g e
Nursing
Responsibilities
Assess hypersensitivity to citicholine.
Monitor patient BP, PR, RR and Temp.
Monitor I/O
Citicoline may be taken with or without food. Take it with or
between meals.
The supplement should not be taken in the late afternoon or at
night because it can cause difficulty sleeping.
Contact the physician immediately if allergic reaction such as
hives, rash, or itching, swelling in your face or hands, mouth or
throat, chest tightness or trouble breathing are experienced.
Advised patient that he may experienced common side effects
such blurred vision, tachycardia hypotension, headache, nausea and
vomiting.
Citicoline therapy should be started within 24 hours of a stroke.
The physician will prescribe the correct dosage and the length of time
it should be taken for a medical condition.
Monitor patients neurological vital signs
10. Note if there are signs of slurring speech
Source 11. http://nursingcrib.com/drug-study/citicoline-indication-and-
nursing-management/
12. http://nurseslabs.com/citicoline-sodium-zynapse-drug-study/
13. http://www.drugs.com/drug-interactions/citicoline-index.html?
filter=1&generic_only=
136 | P a g e
Generic Name
Senna Concentrate
Brand Name Senokot 187 mg Tablet/ granules
Classification Laxative
Indications For the relief of functional constipation through peristaltic stimulation.
Dosage 2 tabs OD @ HS
Action Senokot preparations contain glycosides (the natural principles of senna)
which, upon ingestion, exert no action in the stomach or small intestine.
In the colon, according to current theory, enzymatic action converts the
inactive glycosides into active aglycones which act specifically in the
large bowel through the auerbach’s plexus to stimulate peristalsis.
Side Effects This medication may cause diarrhea, nausea, vomiting, rectal irritation,
stomach cramps or bloating. If these effects continue or become
bothersome, inform your doctor.
Adverse Effects Gastrointestinal Disorders: Common: Abdominal pain. Uncommon:
Feces discoloration, nausea, rectal hemorrhage, vomiting.
Immune System Disorders: Uncommon: Urticaria. Very Rare:
Anaphylactic or anaphylactoid reaction.
Renal and Urinary Disorders: Uncommon: Chromaturia.
Reproductive System and Breast Disorders: Uncommon: Breast milk
discoloration.
Skin and Subcutaneous Tissue Disorders: Uncommon: Erythematous
137 | P a g e
rash, maculopapular rash, perianal irritation.
Interactions 14. No known drug interactions.
Contraindications 15. Do not use when abdominal pain, nausea, vomiting, or other
symptoms of appendicitis are present, acute abdominal diseae,
intestinal hemorrhage, or obstruction , or persistent diarrhea.
16. Store at temperature not exceeding 30 degrees Celsius.
Nursing
Responsibilities
17. Orient self with the 10 rights of giving medication before
administering drug to the patient
18. Assess hypersensitivity if senna concentrates.
19. Advised that patient may experience common side effect such as
diarrhea, nausea and vomiting.
20. Notify physicianif experience: rectal bleeding, rapid heart rate,
weakness, dizziness, fainting, sweating, skin rash, unrelieved
constipation.
21. Advised that taking the medication may cause the urine to turn
pink, red or brownish in color.
22. Monitor patient I/O.
23. Monitor any sign of dehydration.
24. Advised to dink a lot of fluid especially water.
25. Stop taking senna and seek emergency medical attention if you
experience symptoms of a serious allergic reaction including
difficulty breathing; closing of your throat; swelling of your lips,
tongue, or face; or hives.
26. To maintain normal bowel habits, it is important to drink plenty of
fluids (4 to 6 eight ounce glasses a day), increase your intake of
fiber and roughage and exercise regularly.
Source 27. http://www.mims.com/Philippines/drug/info/Senokot/Senokot-
Senokot%20Forte?type=full
138 | P a g e
Generic Name
Atorvastatin calcium
Brand Name Lipitor
Classification Antihyperlipidemic
HMG-CoA reductase inhibitor
Indications Adjunct to diet to reduce LDL cholesterol, total cholesterol,
apolipoprotein B, and triglyceride levels and to increase HDL
cholesterol levels in patients with primary hyoercholesterolemia
(heterozygous familial and nonfamilial) and mied lipidemia
(Fredrickson types IIa and IIb); adjunct to diet to reduce triglyceride
level (Fredrickson type IV); primary dysbetalypoproteinemia
(Fredrickson type III) in patients who don’t respond adequately to diet.
Alone or as an adjunct to lipid-lowering treatments such as LDL
apheresis to reduce total and LDL cholesterol in patients with
homozygous familial hypercholesterolemia.
Heterozygous familial hypercholesterolemia.
To lower cholesterol
To stabilize plaque and prevent strokes through anti-inflammatory and
other mechanisms
Dosage 40mg 1 tab OD @ HS
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Action Reduces plasma cholesterol and lipoprotein levels by inhibiting HMG-
CoA reductase and cholesterol synthesis in the liver and by increasing
the number of LDL receptors on liver cells to enhance LDL uptake and
breakdown.
Side Effects Allergic reaction, facial or generalized edema, flulike symptoms,
infection, lymphadenopathy, weight gain
Adverse Effects CNS: Abnormal dreams, amnesia, asthenia, emotional lability, facial
paralysis, fever, headache, hyperkinesia, lack of coordination, malaise,
paresthesia, peripheral neuropathy,
somnolence, syncope, weakness, insomnia
CV: Arrhythmias, elevated serum CK level, orthostatic hypotension,
palpitations, phlebitis, vasodilation, peripheral edema
EENT: Amblyopia, altered refraction, dry eyes, dry mouth, epistaxis,
eye hemorrhage, gingival hemorrhage, glaucoma, glossitis, hearing loss,
lip swelling, loss of taste, pharyngitis, sinusitis, stomatitis, taste
perversion, tinnitus, rhinitis
ENDO: Hyperglycemia or hypoglycemia
GI: Abdominal or biliary pain, anorexia, colitis, constipation, diarrhea,
duodenal or stomach ulcers, dysphagia, eructation, esophagitis,
flatulence, gastroenteritis, hepatic failure, hepatitis, increased appetite,
140 | P a g e
indigestion, melena, pancreatitis, rectal hemorrhage, tenesmus,
vomiting, dyspepsia, nausea, constipation
GU: Abnormal ejaculation; cystitis; decreased libido; dysuria;
epididymitis;
hematuria; impotence; nephritis; nocturia; renal calculi; urinary
frequency, incontinence, or urgency; urine retention; vaginal
hemorrhage, UTI
Heme: Anemia, thrombocytopenia
Musculoskeletal: Arthralgia, back pain, bursitis, gout, leg cramps,
myalgia, myasthenia gravis, myositis, neck rigidity, tendon contracture,
tenosynovitis, torticollis, arthritis
Respiratory: Dyspnea, pneumonia, bronchitis
Skin: Acne, alopecia, contact dermatitis, diaphoresis, dry skin,
ecchymosis, eczema, jaundice, petechiae, photosensitivity, pruritus,
rash, seborrhea, ulceration, urticaria
Interactions 28. Drug-drug: possible severe myopathy or rhabdomyolysis with
erythromycin, cyclosporine, niacin, antifungals other HMG-CoA
reductase inhibitors
29. Increased digoxin levels with possible toxicity if taken together,
monitor digoxin levels
30. Increased estrogen levels with hormonal contraceptives; monitor
patient on his combination.
Contraindications 31. Contraindicated in patients hypersensitive to drugs and in those
with active liver disease or unexplained persistent elevations of
transaminase levels.
32. Contraindicated in pregnant and breastfeeding women and in
women of child-bearing age.
33. Use cautiously in patients with history of liver disease or heavy
alcohol use
34. Withhold or stop drug in patients at risk for renal failure caused
by rhabdomyolysis resulting from trauma; in serious, acute
141 | P a g e
conditions that suggest myopathy; and in major surgery, severe
acute infection, hypotension, uncontrolled seizures, or severe
metabolic, endocrine, or electrolyte disorders.
35. Use of Atorvastatin in children has been limited to those older
than age 9 with homozygous familial hypercholesterolemia.
36. Active hepatic disease, hypersensitivity to atorvastatin or its
components, unexplained persistent rise in serum transaminase
level
Nursing
Responsibilities
37. Assess for hypersensitivity of the medication to the patient.
38. Assess patient for hepatic dysfunction
39. Monitor patient’s VS
40. Monitor I/O.
41. Atorvastatin is used in patients with homozygous familial
hypercholesterolemia as an adjunct to other lipid-lowering
treatments or alone only if other treatments aren’t available.
Atorvastatin adjunct to—not a substitute for—low-cholesterol
diet.
42. Atorvastatin may be used with colestipol or cholestyramine for
additive antihyperlipidemic effects.
43. Advised patient to expect atorvastatin to be used in patients
without obvious coronary artery disease (CAD) but with
multiple risk factors (such as age 55 or over, smoker, history of
hypertension or low HDL level, or family history of early CAD).
Drug is used to reduce risk of MI, angina, and adverse effects of
revascularization procedures..
44. Liver function tests to be performed before atorvastatin therapy
starts, after 6 and 12 weeks, with each dosage increase, and
every 6 months thereafter.
45. Expect to measure lipid levels 2 to 4 weeks after therapy starts,
to adjust dosage as directed, and to repeat periodically until lipid
levels are within desired range.
142 | P a g e
46. Take drug at the same time each day to maintain its effects.
* Take a missed dose as soon as possible. If it’s almost time for
the next dose, the missed dose should be skipped. DO NOT
double the dose.
* Consult prescriber before taking OTC niacin because of
increased risk of rhabdomyolysis.
* Notify prescriber immediately if he develops unexplained
muscle pain, tenderness, or weakness, especially if accompanied
by fatigue or fever.
* Advice patient to use only after diet and other nondrug
therapies prove ineffective. Patient should follow a standard
low-cholesterol diet before and during therapy.
* Warn patient to avoid alcohol.
Source 47. http://medicaldrugstudy.info/atorvastatin-calcium-drug-study
48. Nursing 2006 Drug Handbook, Lippincott Williams & Wilkins,
page 152-153
143 | P a g e
Generic Name
Nicardipine Hydrochloride
Brand Name Cardene, Cardene SR
Classification Calcium channel blockers; antianginal; antihypertensive
Indications Nicardipine is used with or without other medications to treat high
blood pressure (hypertension). Lowering high blood pressure helps
prevent strokes, heart attacks, and kidney problems. Nicardipine is
called a calcium channel blocker. It works by relaxing blood vessels so
blood can flow more easily.Nicardipine is also used to prevent certain
types of chest pain(angina). It may help to increase your ability to
exercise and decrease the frequency of angina attacks. This medication
must be taken regularly to be effective. It should not be used to treat
attacks of chest pain when they occur. Use other medications (such as
sublingual nitroglycerin) to relieve attacks of chest pain as directed by
your doctor. Consult your doctor or pharmacist for details.
Dosage 10mg
Action These medications block the movement of calcium into the smooth
muscle cells surrounding the arteries of the body. Since calcium
promotes contraction of muscle, blocking calcium entry into the muscle
cells relaxes the arterial muscles and causes the arteries to become
larger. This lowers blood pressure, which reduces the work that the
heart must do to pump blood to the body. Reducing the work of the
heart lessens the heart muscle's demand for oxygen and thereby helps
prevent angina (heart pain) in patients with coronary artery disease.
Unlike verapamil or diltiazem, nicardipine has little effect on heart
muscle or on electrical conduction within the heart.
Side Effects Side effects include swelling of the feet (edema), dizziness,headaches,
144 | P a g e
flushing, palpitations, and nausea. Fainting, over growth of the gums,
and rash also may occur. It may increase heart rate due to a drop in
blood pressure. Nicardipine sometimes causes an increase in the
frequency and duration of angina. The reason for this side effect is not
clearly understood. Excessively low blood pressure can occur in rare
instances, especially during initiation of treatment or following
adjustments of dosage.
Adverse Effects CV: hypotension, arrhythmias, asytole
Interactions Rifampin, phenobarbital, phenytoin (Dilantin, Dilantin-125),
oxcarbazepine (suspension oral Trileptal; oral Trileptal)
andcarbamazepine (Tegretol, Tegretol XR , Equetro, Carbatrol) may
reduce blood levels of nicardipine by increasing its metabolism
(destruction) in theliver. Therapy should be monitored and drug doses
should be adjusted accordingly when nicardipine is used with these
drugs.
Itraconazole (Sporanox), ketoconzole, or clarithromycin (Biaxin) may
increase blood levels of nicardipine by reducing its breakdown in the
liver and lead to toxicity from nicardipine.
It increases serum levels and toxicity of cyclosporine
Contraindications 49. contraindicated with allergy to nicardipine, pregnancy, lactation
50. use cautiously with impaired hepatic or renal function, sick
sinus syndrome, heart block (second-or third-degree)
Nursing
Responsibilities
51. Assess patient to allergy to nicardipine.
52. Checked for any sign of imapaired hepatic or renal function,
sick sinus syndrome, or heartblock.
53. Physical assessment in skin for color, edema and lesions.
54. Monitor patient carefully (BP and cardiac rhythm) while drug is
being titrated to therapeutic dose; dosage may be increased
more rapidly in hospitalized patients under close supervision.
145 | P a g e
55. Monitor BP carefully with concurrent doses of nitrates.
56. Monitor cardiac rhythm regularly during the stabilization of
dosage and long term therapy.
57. Monitor I/O.
58. Provide small frequent meals if GI upset occurs.
59. Advised patient that he may experience some side effects
nausea, vomiting and headache.
60. Advised patient to report irregular heartbeat, SOB, swelling of
hands and feet, pronounced dizziness, constipation.
Source
61. http://www.medicinenet.com/nicardipine_capsule-oral/
page4.htm
62. 2007 Lippincott’s nursing drug guide page: 850-851
63.
Generic Name
Neuro Aid Capsule
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Brand Name MLC 601; MOleac
Classification M03BX - Other centrally acting agents ; Used as muscle relaxants.
Indications It helps support neurological, motor and cognitive functions resulting in a
better quality of life.
Dosage 4 capsule TID
Action NeuroAiD has been proved to stimulates the secretion of BDNF. The in
vitro and in vivo results show that NeuroAiD makes cell more resistant
against glutamate aggression, increases neurite outgrowth and connectivity
as well as reduces the infarct volume, therefore results in better neurological
functions.[3]
Side Effects May cause increase thirsty and dry mouth
Adverse Effects vomiting, nausea, and mild headaches
Interactions 64. Research on drug interactions with aspirin as an antiplatelet agent
were conducted and revealed no severe side effect. Yet today, no
other interaction researches have been recorded so far.
Contraindications 65. Not allowed for use in pregnancy, lactating mothers and children
below 18.
Nursing
Responsibilities
66. Orient self with the 10 rights of giving medication before
administering drug to the patient
67. Note for the age and condition of the patient.
68. Advised that patient may experience common side effects such as
thirsty and dry mouth.
69. Advised to report immediately if experienced headches, nausea and
vomiting.
70. Advised to increased oral fluid to lessen the dryness experienced.
71. Monitor Patient’s VS.
72. Checked the GCS.
73. Checked the motor response and reflex.
Source 74. http://www.neuroaid.com.sg/neuroaid-leaflet.html
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75. http://www.wisegeek.com/what-is-neuroaid.htm
76. http://www.neuroaid.com/en/medical-professional/what-is-
neuroaid.html
Generic Name
Cerebrolysin
Brand Name Ebewe; Bulgaria
Classification C04A - PERIPHERAL VASODILATORS ; Used as peripheral vasodilators.
Indications 1. Complex therapy of endogenous depression (in combination with
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psychotherapy and antidepressants)
2. Post-apopletic complications
3. Chronic cerebrovascular disorders
4. Brain and spinal cord injuries (craniocerebral trauma, post operative
trauma, concussion, cerebral contusion,)
5. Alzheimer disease
6. Ischemic stokes (treatment the complications)
7. Mental retardation
8. Senile dementia
Dosage 2152mg/ml/amp
Action is a nootropic drug which contains low molecular biologically active
neruropeptides, which penetrate through blood-brain barrier and act directly
on the nerve cells. The drug possesses a multimodal organo-specific effect on
the brain, provides metabolic regulation, neuroprotection, functional neuro-
modulation, and neurotrophic activity as well.
Cerebrolysin improves the efficiency of aerobic energy metabolism in the
brain, improves the intracellular protein synthesis in the developing and aging
brain.
Side Effects heat, sweating, dizziness, tachycardia or fibrillation.
agitation, hypertension, hypotension, lethargy, tremors, depression, apathy,
dizziness, headache, shortness of breath, diarrhea, nausea) were identified
during clinical trials and occurred equally in patients, receiving
Cerebrolysin , and patients taking placebo.
Adverse Effects1. Digestive system: loss of appetite, indigestion, diarrhea, constipation,
nausea and vomiting.
2. Central nervous system and peripheral nervous system: rarely -
excitement, vaggressive behavior, confusion, insomnia, seizures,
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convulsions.
3. Allergic reactions: hypersensitivity reactions, headache, pain in the
neck, legs, lower back, shortness of breath, chills and collaptoid state.
4. Local reactions: hyperemia of the skin, itching and burning at the
injection site.
5. According to the results of clinical studies there were reported the
following Cerebrolysin side effects:
6. Cardiovascular system: hypertension, hypotension.
7. Central nervous system and peripheral nervous system: fatigue,
tremor, depression, apathy, dizziness.
Interactions 8. Cerebrolysin may enhance the effects of antidepressants and MAO
inhibitors in concomitant use. The drug is not compatible with lipid
containing solution and solutions which change pH. The medication
should not be mixed with aminoacids solution.
Contraindication
s
1. Acute kidney insufficiency
2. Epileptic status
3. Known hypersensitivity to any of the drug ingredients
Nursing
Responsibilities
4. Assess for hypersensitivity of the drug to the patient.
5. Assess any signs of kidney dysfunction,
6. Checked the other medications intake, it may cause drug interactions.
7. Advised patient that he may experience the common side effects
listed.
8. Advised to report immediately if any drug reactions occur.
9. Monitor I/O.
10. Checked patient’s VS
11. Checked patient’s NVS
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12. Checked patient’s level of consciousness.
13. Instructed to increased oral fluid intake.
Source 14. http://www.drugs-health.com/nootropics-cerebrolysin-c-76_80.html
15. http://www.mims.com/Philippines/drug/info/Cerebrolysin/?type=full
Generic Name:
Paracetamol (acetaminophen)
Brand name: abenol, acephen,aceta,actamin, aminofen, tempra, valorin, panadol, feverall,
Biogesic
Classification: Cardiovascular system drugs; Nonopioid analgesics and antipyretics,
Pregnancy risk category B
Indication: 1. Mild pain or fever
Dosage: 500mg IVTT q6 hours
Action: Unknown. Thought to produce analgesia by blocking pain impulse by
inhibiting synthesis of prostaglandin in the CNS or of other substances that
sensitize pain receptors to stimulation. The drug may relieve fever through
central action in the hypothalamic heat-regulating center.
Route Onset Peak Duration
P.O./ P.R. Unknown ½-2 hours 3-4hr
Contraindication: 1. Many OTC and prescription products contain acetaminophen, be
aware of this when calculating total daily dose.
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2. Use liquids form for children and patients who have difficulty
swallowing
3. In children, do not exceed five doses in 24 hours
Side effects: jaundice, rash
Adverse Effects: Hematologic: hemolytic anemia, neutropenia, leucopenia, pancytopenia
Hepatic: jaundice
Metabolic: hypoglycemia
Skin: rash, urticaria
Drug interactions: Drug-drug:
1. Barbiturates, carbamazepine, hydantoins, rifampin, sulfinpyrazone:
high doses or long-term use of these drugs may reduce therapeutic
effects and enhance hepatotoxic effects of acetaminophen
Drug-food: caffine: may enhance analgesic effects of acetaminophen.
Drug-lifestyle: alcohol use: may increase risk of hepatic damage
Nursing
Responsibilities:
2. Assess vital signs
3. Identify indications for therapy and expected outcomes.
4. Document presence of fever. Rate pain, noting type, onset, location,
duration and intensity.
5. Do not take for more than 5 days for pain in children or for more
than 3 days for fever without consulting the doctor.
6. In children, don’t exceed five doses in 24 hours.
7. Report pallor, weakness and palpitations.
8. Advise client to take only as directed and with food or milk to
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minimize GI upset
9. Many OTC and prescription products contain paracetamol; be aware
of this when calculating total daily dose.
10. Review with parents the difference between the concentrated
dropper dose formulation and teaspoon dose formulation.
11. Any unexplained pain or fever that persists longer than 3-5 days
requires medical evaluation
Sources: 12. http://www.drugs.com/paracetamol.html. 2009
13. Nursing2006 drug handbook. 26th edition. Lippincott Williams &
Wilkins. Page 351-353
14. http://www.mims.com/USA/drug/info/paracetamol/. 2011
Generic Name:
Omeprazole
:Losec Prilosec
Classification: gastrointestinal agent; proton pump inhibitor
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Indication: 15. Duodenal and gastric ulcer. Gastroesophageal reflux
disease including severe erosive esophagitis (4 to 8 wk treatment).
Long-term treatment of pathologic hypersecretory conditions such
as Zollinger-Ellison syndrome, multiple endocrine adenomas, and
systemic mastocytosis. In combination with clarithromycin to treat
duodenal ulcers associated with Helicobacter pylori.
Dosage: 40 mg capsules
Action: An antisecretory compound that is a gastric acid pump inhibitor. Suppresses
gastric acid secretion by inhibiting the H+, K+-ATPase enzyme system [the
acid (proton H+) pump] in the parietal cells.
Contraindication: 16. Long-term use for gastroesophageal reflux disease, duodenal ulcers;
lactation.
Side effects: Asthenia, vertigo, insomnia, anxiety, paresthesias, dream abnormalities,
inflammation, dry skin, pruritus
Adverse Effects: CNS:Headache, dizziness, fatigue.
GI:Diarrhea, abdominal pain, nausea, mild transient increases in liver
function tests.
Urogenital:Hematuria, proteinuria.
Skin:Rash.
Drug interactions: Drug-drug: increased serum levels and potential increase in toxicity of
benzodiazephines, phenytoin, warfarin.
Decreased absorption with sucralfate, give these drugs at least 30 min apart.
Nursing
Responsibilities:
17. Assess for hypersensitivity to omeprazole.
18. Physical assessment: skin (lesions and color)
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19. Monitor I/O, it affect the urinary output.
20. Checked VS. abnormal results in RR.
21. Take medications with food
22. Do not crush or chew the capsule
23. Caution patient to avoid alcohol, salicylates, ibuprofen; may cause
GI irritation
24. Patient may experience anorexia; small frequent meals may help to
maintain adequate nutrition.
25. Report severe headache, unresolved severe diarrhea, or changes in
respiratory status.
Sources: 26. Nursing2006 drug handbook. 26th edition. Lippincott Williams &
Wilkins. Page 881-882
27. http://www.mims.com/USA/drug/info/omeprazole/. 2011
Generic Name
Hydralazine Hydrochloride
Brand Name Alphapress, Apresoline, Novo-Hyzalin, Supres
Classification Cardiovascular System Drug, Antihypertensive, Pregnancy risk category C
Indications Essential hypertension (orally, alone or with other antihypertensives), severe
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essential hypertension (parenterally to lower blood pressure quickly)
Dosage 5mEq IVTT PRN for diastolic blood pressure over 110mmHg
Action Unknown. A direct-acting vasodilator that relaxes arterial smooth muscle.
Route Onset Peak Duration
P.O. 20-30 min 1-2 hours 2-4 hours
I.V. 5-20 min 10-80 min 2-6 hours
I.M. 10-30 min 1 hour 2-6 hours
Side Effects Headache, tachycardia, angina pectoris, palpitations, nausea, vomiting,
diarrhea, anorexia, neurotopenia, leucopenia,, agranulocytopenia,
agranulocytosis, thromobocytopenia with or without purpura
Adverse Effects CNS: peripheral neuritis, headache, dizziness;
CV: orthostatic hypotension, tachycardia, edema, angina pectoris,
palpitations;
EENT: nasal congestion
GI: nausea, vomiting, diarrhea, constipation, anorexia
Hemotologic: neurotopenia, leucopenia, agranulocytopenia,
agranulocytosis, thromobocytopenia with or without purpura
Skin: rash
Interactions Drug-drug:
28. Diazoxide, MAO inhibitors: May cause severe hypotension. Use
together cautiously.
29. Diuretics, other hypotensive drugs: May cause excessive
hypotension. Dosage adjustment may be needed.
30. Indomethacin: May decrease effects of hydralazine. Monitor blood
pressure.
31. Metoprolol, propanolol: May increase levels and effects of beta
blockers. Monitor patient closely and there is a need to adjust the
dosage.
Contraindications 32. Contraindicated in patients sensitive to the drug,
33. Those with coronary artery disease or mitral valvular rheumatic
heart disease.
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34. Use cautiously in patients with suspected cardiac disease, CVA,
severe renal impairment and in those taking antihypertensives.
Nursing
Responsibilities
35. Orient self with the 10 rights of giving medication before
administering drug to the patient.
36. Monitor patient’s blood pressure, pulse rate and weight gain
frequently. Hydralazine may decrease sodium retention and
tachycardia and to prevent angina attacks.
37. Monitor CBC, lupus eryhtematosus cell preparation, and antinuclear
antibody titer determination before therapy and periodically during
long-term therapy.
38. Monitor patient closely for signs and symptoms of lupuslike
syndrome, and notify physician immediately if they develop.
39. Improve patient compliance by giving the drug and asking the
patient not to meddle with the IV regulation.
40. Instruct patient to take oral form with meals to improve absorption.
41. Instruct patient not to rise quickly off the bed.
42. Instruct patient to avoid sudden changes in position.
43. Inform the patient that low blood pressure dizziness can be
minimized by rising slowly and avoidance of sudden position
changes.
44. Tell patient to notify the physician of unexplained prolonged general
tiredness or fever, muscle or joint aching, or angina.
Source 45. Nursing 2006 Drug Handbook, Lippincott Williams & Wilkins. Page
292-293
46. http://www.drugs.com/mtm/hydralazine.html - 2010
47. http://www.rxlist.com/apresoline-drug.htm - 2011
Generic Name
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Insulin (Regular)
Brand Name Humulin R, Novolin R, Regular Insulin, Pork Regular Iletin II, Regular
Purified Pork Insulin, Velosulin, Velosulin BR, Velosulin Human
Classification hormone and synthetic substitute; antidiabetic agent; insulin
Indications Emergency treatment of diabetic ketoacidosis or coma, to initiate therapy in
patient with insulin-dependent diabetes mellitus, and in combination with
intermediate-acting or long-acting insulin to provide better control of blood
glucose concentrations in the diabetic patient. Used IV to stimulate growth
hormone secretion (glucose counter regulatory hormone) to evaluate
pituitary growth hormone reserve in patient with known or suspected
growth hormone deficiency. Other uses include promotion of intracellular
shift of potassium in treatment of hyperkalemia (IV) and induction of
hypoglycemic shock as therapy in psychiatry.
Dosage 100 units/mL
Action Short-acting, clear, colorless solution of exogenous unmodified insulin
extracted from beta cells in pork pancreas or synthesized by recombinant
DNA technology (human). Enhances transmembrane passage of glucose
across cell membranes of most body cells and by unknown mechanism may
itself enter the cell to activate selected intermediary metabolic processes.
Promotes conversion of glucose to glycogen.
Side Effects Rash
Hives
Itching
Swelling of the mouth or throat
Wheezing or other difficulty breathing
Adverse Effects BodyWhole:Most adverse effects are related to hypoglycemia; ana-phylaxis
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(rare), hyperinsulinemia [Profuse sweating, hunger, headache, nausea,
tremulousness, tremors, palpitation, tachycardia, weakness, fatigue,
nystagmus, circumoral pallor; numb mouth, tongue, and other paresthesias;
visual disturbances (diplopia, blurred vision, mydriasis), staring expression,
confusion, personality changes, ataxia, incoherent speech, apprehension,
irritability, inability to concentrate, personality changes, uncontrolled
yawning, loss of consciousness, delirium, hypothermia, convulsions,
Babinski reflex, coma. (Urine glucose tests will be negatives).
CNS:With overdose, psychic disturbances (i.e., aphasia, personality
changes, maniacal behavior).
Metabolic:Posthypoglycemia or rebound hyperglycemia (Somogyi effect),
lipoatrophy and lipohypertrophy of injection sites; insulin resistance.
Skin:Localized allergic reactions at injection site; generalized urticaria or
bullae, lymphadenopathy.
Interactions Drug-drug: Angiotensin-converting enzyme inhibitors (ACE inhibitors);
Octreotide (Sandostatin®); Monoamine oxidase inhibitors (MAOIs); Beta
Blockers.
Drug- Diagnostic: Interference Large doses of insulin may increase urinary
excretion of VMA. Insulin can cause alterations in thyroid function
tests and liver function test and may decrease serum potassium and serum
calcium.
Contraindications 48. Hypersensitivity to insulin animal protein.
Nursing
Responsibilities
49. Orient self with the 10 rights of giving medication before
administering drug to the patient.
50. Note: Frequency of blood glucose monitoring is determined by the
type of insulin regimen and health status of the patient.
51. Lab tests: Periodic postprandial blood glucose, and HbA1C. Test
urine for ketones in new, unstable, and type 1 diabetes; if patient
has lost weight, exercises vigorously, or has an illness; whenever
blood glucose is substantially elevated.
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52. Notify physician promptly for presence of acetone with sugar in the
urine; may indicate onset of ketoacidosis. Acetone without sugar in
the urine usually signifies insufficient carbohydrate intake.
53. Monitor for hypoglycemia at time of peak action of insulin. Onset
of hypoglycemia (blood sugar: 50–40 mg/dL) may be rapid and
sudden.
54. Check BP and blood glucose and ketones every hour during
treatment for ketoacidosis with IV insulin.
55. Monitor I/O.
56. Give patients with severe hypoglycemia glucagon, epinephrine, or
IV glucose 10%–50%. As soon as patient is fully conscious, give
oral carbohydrate (e.g., dilute corn syrup or orange juice with sugar,
Gatorade, or Pedialyte) to prevent secondary hypoglycemia.
Source 57. http://nursingcrib.com/drug-guides/insulin-regular/
58. http://endocrine-system.emedtv.com/regular-insulin/drug-
interactions-with-regular-insulin.html
XV- NURSING THEORIES
Sister Callista Roy’s
Adaptation theory
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Adaptation theory of Sister Callista Roy views a person as an adaptive system with
coping processes. She described the person as a whole comprised of parts which functions as a
unity for some purposes. In relation to our patient, we think that our patient needs to adapt to the
changes related to his disease and that it is a need to undergo into some modification when it
comes to his health because we, as a part of the medical team desires to give the best possible
care to our patients. As a student nurse, the interventions we perform ultimately elicit a response
from our patients. It is on how we render service to our clients and how we treat them
individually and on the nature and extent of the nursing intervention. Our patients may or may
not actually adapt according to our expectations. This theory assumes that a person should be
aware about his or herself and the environment he is into.
The patient should be the one to identify his capabilities and needs in the human adaptive
system. He should be able to select appropriate approaches for her and implement it as well as to
evaluate whether it had helped him in his daily living. Nurses serve as a guide in helping the
patients in this cycle which we call the nursing process starting from assessing what is the major
problem up to evaluating the outcome.
The patient should adapt to the 4 adaptive modes which includes the physiologic-
physical, self- concept group identity, role function and interdependence. In the physiologic-
physical, being physically fit is not always consider as healthy and therefore in the case of our
client, we must remind him that by eating the right kind of food that are not contraindicated by
his physician.
The last adaptive mode is interdependence, which includes the giving and receiving of
love form his family, also having rest and towards to society and have the core values through
effective relations and communications with his significant other.
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Faye Glenn G. Abdellah’s
TWENTY ONE NURSING PROBLEMS
"Nursing is based on an art and science that mould the attitudes, intellectual
competencies, and technical skills of the individual nurse into the desire and ability to help
people, sick or well, cope with their health needs." - Abdellah
This theory helps us student nurse utilize problems from our patient. It helps Decides the
appropriate course of action to take in terms of relevant nursing principles, providing continuous
care of the individual’s total needs helps the individual to become more self directing in attaining
or maintaining a healthy state of mind & body and helping the individual to adjust to his
limitations and emotional problems. It helps our patient especially in healthy lifestyle since our
patient really needs a healthy lifestyle due to his disease which is chronic kidney disease.
This theory is about nursing care for whole individual with the help of the 21 typology Abdellah
made:
Abdellah’s Typology of 21 Nursing Problems are as follows:
1. To promote good hygiene and physical comfort
2. To promote optimal activity, exercise, rest, and sleep
3. To promote safety through prevention of accidents, injury, or other trauma and through the
prevention of the spread of infection
4. To maintain good body mechanics and prevent and correct deformities
5. To facilitate the maintenance of a supply of oxygen to all body cells
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6. To facilitate the maintenance of nutrition of all body cells
7. To facilitate the maintenance of elimination
8. To facilitate the maintenance of fluid and electrolyte balance
9. To recognize the physiologic responses of the body to disease conditions
10. To facilitate the maintenance of regulatory mechanisms and functions
11. To facilitate the maintenance of sensory function
12. To identify and accept positive and negative expressions, feelings, and reactions
13. To identify and accept the interrelatedness of emotions and organic illness
14. To facilitate the maintenance of effective verbal and nonverbal communication
15. To promote the development of productive interpersonal relationships
16. To facilitate progress toward achievement of personal spiritual goals
17. To create and maintain a therapeutic environment
18. To facilitate awareness of self as an individual with varying physical, emotional, and
developmental needs
19. To accept the optimum possible goals in light of physical and emotional limitations
20. To use community resources as an aid in resolving problems arising from illness
21. To understand the role of social problems as influencing factors in the cause of illness
Abdellah described nursing as a service to individual, to families and therefore to the
society. She acknowledged the influence of Henderson and expanded Henderson’s 14 needs into
her own 21 problems that she believed would serve as a knowledge base for nursing.
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In her nursing practice, she strongly believed and supported the idea that nursing research would
be the key factor in helping nursing to advance and grow into a true respectable profession. It
was through her research that what is now known and seen as nursing diagnosis was developed.
Abdellah stated that people have physical, emotional and sociological needs and that these needs
are overt needs which consist largely of physical needs which are covert in nature such as
emotional, social and interpersonal needs – which are often perceived incorrectly. Abdellah
averred that – the patient is the justification for the existence of nursing. The individuals
(families) are the recipients of nursing care and health or achieving it is the purpose of nursing.
Abdellah defined man, health, environment/society and nursing. And of nursing she stated that
“Nursing is a service to individuals, families and therefore to society. The goal of nursing
according to her is the physical, emotional, intellectual, social and spiritual functioning of the
client which pertains to holistic care.
Virginia Henderson’s
14 Basic Human Needs
Virginia Henderson's 14 Basic Human Needs Theory emphasizes the importance of
patient independence that the patient will continue to progress after being released from the
hospital. Henderson described the role of the nurse as substitutive, which is doing tasks for the
patient; supplementary, which is helping the patient do the tasks; or complementary, which is
working with the patient to do tasks. All of these roles are to help the patient become as
independent as possible.
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Since our patient is admitted at the hospital and is for treatment, it is our duty as nurses to
do tasks for him, to help him and to work with him in order to attain his independence as
possible towards maintaining his health. It is also our responsibility to take care of our patient
while he is still at the hospital so that he, later on, will be able to take care of himself
independently. This is why health teachings are very important because the care that we give to
our patient is not limited only at the hospital but our patient can also practice our way of care
even at home. But before giving care to our patient, we nurses should know by heart the primary
needs that humans have. With this, we will be able to plan carefully and accordingly on the
interventions to be done to our patient. This is why Henderson’s theory is considered as the basis
for nursing care.
Henderson categorized nursing activities into fourteen components based on human needs.
The fourteen components of Henderson's concept are as follows:
1. Breathe normally. Eat and drink adequately.
1. It is necessary for us to breathe because if we stop breathing we eventually die. To eat
and drink adequately is for our body to maintain balance or keep working. We need to eat
food that contains nutrients necessary for survival including water, which is very needed
by our body. It regulates heat, cleanses the body and provides fluid for the body.
2. Eliminate body wastes.
3. Eliminate by all avenues of elimination. Our body then absorbs the nutrients and what is
left are unnecessary materials or toxics that must be taken out of the body and this is
process by elimination of urine or feces.
4. Move and maintain desirable postures.
5. For our body to function normally we must maintain desirable body positions.
6. Sleep and Rest
7. Our body can function 24 hours a day but if prolonged we eventually die. We need to rest
to regain strength, to grow and to develop.
8. Select suitable clothes-dress and undress.
9. Select suitable clothing. We must select suitable clothing prior to temperature of the
environment to maintain normal body temperature.
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10. Maintain body temperature within normal range by adjusting clothing and modifying
environment.
11. Maintain body temperature within normal range. If body temperature declines
or increases, both are risky.
12. Keep the body clean and well groomed and protect the integument.
13. Keeping the body clean lessens the risk of attaining infection or disease.
14. Avoid dangers in the environment and avoid injuring others.
15. To avoid dangers in the environment we must be extra very careful to our actions
16. Communicate with others in expressing emotions, needs, fears, or opinions
17. Communicate with others makes life much easier and comfortable through increasing
social health.
18. Worship according to one's faith
19. We humans have different believes, have different Gods but what is common to us is
that we believe in God whom we believe is the giver of our lives and is the source of our
strength and intellectual thinking.
20. Work in such a way that there is a sense of accomplishment
21. We work or do something to keep us alive, something that makes us happy and complete.
22. Play or participate in various forms of recreation.
23. Play or participate in various forms of recreation. To aid our lives with better standards of
living we usually play significant roles in various forms of recreation.
24. Learn, discover, or satisfy the curiosity that leads to normal development and health and
use the available health facilities
25. Basic needs are essential for survival and to daily life activities and experiences
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XVI- NURSING CARE PLAN
Patient’s Name: Patient B Diagnosis: Cerebrovascular bleed capsuloganglionic hypertension II
Gender: Male Ward: Neuro
DATE CUES NEEDS NURSING DIAGNOSIS
WITH RATIONALE
OBJECTIVE
OF
CARE
NURSING INTERVENTIONS WITH RATIONALE
EVALUATION
December 6, 2012
3-11 Shift
3 PM
SUBJECTIVE:
Subjective:
“Wala mn koy kauban diri pag mtulog nako, buntag na sila mubalik.”
Self-Perception – Self-Concept Pattern
Anxiety related to absence of a family member/ support group.
®Absence of a family member during illness/ hospitalization of an individual may cause
After 8 hour span of care, patient will appear relaxed and anxiety will be lessened as evidenced by verbalization of relief of anxiety.
1. Establish rapport to the client and family.
® Establishing rapport to the client and family will enable the nurse to gain the confidence and cooperation of the client.
2. Listen actively to the patient. ® Patient will feel comforted.
3. Speak in brief statements and use simple words.
® This allows the patient to understand what
December 6, 2012
11 PM
GOAL MET:
After 8 hour span of care, the patient was able to verbalize a
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Objective:
>Restlessness/anxiety
>Lack of pleasure in activities
depression and anxiety due to the feeling of being alone.
Nurse’s
Pocket Guide by Doenges, Moorhouse and Murr
you are saying. Simple words are applicable for a child.
4. Give patient a little advice and pleasing ideas.
® This will help stimulate the patient to be relaxed.
5. Advice the patient to play or divert attention to hobbies.
® This will help the patient forget about his current feelings.
6. Teach the patient about relaxation techniques, such as guided imagery.
® This soothes the mindset of the patient and will help him relax.
7. Tell the patient verbalize feelings.
® This helps patient to relax mentally and physically.
relief of anxiety: “Maayo na lng naa si nanay na watcher dra sa pikas, naay mubantay sa akoa. Mubalik bitaw si bayot ugma sayo sa buntag”.
>Patient appears to be relaxed and comfortable
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8. Encourage social interactions.
® Social interactions lessen anxiety and loneliness.
9. Advice the watcher to be with the patient as much as possible.
® This helps reduces loneliness and anxiety.
1. Advice the watcher to seek for a spiritual advice/help.
® Spiritual advice can strengthen one’s faith and reduces anxiety.
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Date, Time and Shift
CueNeeds/Patterns
Nursing Diagnosis
Objective Nursing Intervention Nursing Evaluation
DECEMBER
07,
2012
4:00 PM
Objective:1. Slur
red speech
2. Difficulty in expressing ideas and feelings
PERCEPTUAL
COGNITIVE
PATTERN
Impaired verbal communication related to cognitive function secondary to cerebrovascular accident
Within 6 hours of nursing interventions, the patient will be able to establish method of communication in which needs can be expressed as evidenced by using resources appropriately to express needs.
1. Assess type/degree of dysfunctionR: Helps determine area and degree of brain involvement and difficulty patient has with any or all steps of the communication process.
2. Differentiate aphasia from dysarthria
R: Choice of interventions depends on type of impairment.
3. Listen for errors in conversation and provide feedback
R: Patient may lose ability to monitor verbal output and be unaware that communication is not sensible.
4. Ask patient to follow simple commands (e.g., “Shut your eyes,” “Point to the door”); repeat simple words/ sentences
R: Test for receptive aphasia
5. Have patient produce simple sounds, e.g., “Sh,” “Cat”.
R: Identifies dysarthria, because motor components of speech (tongue, lip
GOAL MET!
12/07/1210:00 PM
After 6 hours of nursing interventions, the patient
was able to use other resources as a means of
communication as evidenced by the patient using a pen to express his needs using his left
hand.
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movement, breath control) can affect articulation and may/may not be accompanied by expressive aphasia.
6. Ask patient to write name and/or a short sentence. If unable to write, have patient read a short sentence.
R: Tests for writing disability (agraphia) and deficits in reading comprehension (alexia), which are also part of receptive and expressive aphasia.
7. Provide alternative methods of communication, e.g., writing or felt board, pictures. Provide visual clues gestures, pictures, “needs” list, demonstration).R: Provides for communication of needs/desires based on individual situation/underlying deficit.
8. Anticipate and provide for patient’s needs.
R: Helpful in decreasing frustration when dependent on others and unable to communication desires.
9. Talk directly to patient, speaking slowly and distinctly. Use yes/no questions to begin with, progressing in complexity as patient responds.R: Reduces confusion/anxiety at having to process and respond to large amount of information at one
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time
10. Speak in normal tones and avoid talking too fast. Give patient ample time to respond. Talk without pressing for a response.
R: Patient is not necessarily hearing impaired, and raising voice may irritate or anger patient.
11. Encourage SO/visitors to persist in efforts to communicate with patient, e.g., reading mail, discussing family happenings even if patient is unable to respond appropriately.
R: It is important for family members to continue talking to patient to reduce patient’s isolation, promote establishment of effective communication, and maintain sense of connectedness with family.
12. Advise the patient to consult with speech therapist.
R: Assesses individual verbal capabilities and sensory, motor, and cognitive functioning to identify deficits/therapy needs.
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DATE CUES NEEDS NURSING DIAGNOSIS
WITH RATIONALE
OBJECTIVE
OF
CARE
NURSING INTERVENTIONS WITH RATIONALE
EVALUATION
December 6, 2012
3-11 Shift
3 PM
OBJECTIVE:
Subjective:“Maglisod na man siya maglihok karon kay dili na niya kaya ang iyahang lawas.” As verbalizedby the watcher.
Objective:> Generalized weakness
>With pale skin
>With fatigability
Activity – Exercise Pattern
Impaired physical mobility related to neuromuscular involvement: weakness, paresthesia, as evidenced by impaired coordination, limited range of motion, decreased muscle strength secondary to CVA.
®A stroke is an upper motor neuron lesion and results in
Short term:
After 8 hours of nursing care the patient will be have improved physical mobility as evidenced by:
1. Verbalization of understanding of situation or risk factors and individual treatment regimen and safety measures.2. Maintain position of function and skin integrity as
1. Establish rapport to the client and family.
® Establishing rapport to the client and family will enable the nurse to gain the confidence and cooperation of the client.
2. Reassess ability to carry out ADLs (e.g., feeding, dressing, grooming, bathing and ambulating) on regular basis.
® To determine the aspect of ADL that is difficult to the patient.
3. Change position at least every two hours and more often if placed on the affected side.
® Reduces risk of tissue ischemia and bedsores.
4. Position in prone position once or
December 6, 2012
11 PM
GOAL MET:
After the span of care, the patient was able to:
1. Maintain position of function and skin integrity as evidenced by absence of foot drop and
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>Paralysis control over motor movements. Because the upper motor control on one side of the body may reflect damage to the upper motor neurons on the opposite side of the brain thus resulting to impairment in physical mobility.
Nurse’s Pocket Guide by Doenges, Moorhouse and Murr
evidenced by absence of contractures, foot drop, and so forth. 3. Maintain or improve strength and function of affected and/ or compensatory part.
twice a day if client can tolerate.
® Helps maintain functional hip extension
5. Position extremities in functional position; use footboard. Maintain neutral position of head.
® Prevents contractures or foot drop and facilitates use when function returns.
6. Observe affected side for color, edema, or other signs of compromised circulation.
® Edematous tissue is more easily traumatized and heals more slowly.
7. Inspect skin regularly, particularly over bony prominences. Gently massage any reddened area.
® Pressure points over bony prominences are most at risk for decreased perfusion.
8. Assist in maintaining sitting balance.
® Aids in retaining neuronal pathways,
bedsores
2. Verbalize understanding of treatment regimen and safety measures
1. Maintained strength in the functional parts
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enhancing proprioception and motor response.
9. Set goals with client for increasing participation in activities, exercises or position changes.
® Promotes sense of expectation of progress and provides some sense of independence.
10. Encourage patient to assist with movement and exercises using unaffected side to support or to move weaker side.
® May respond as if affected side is no longer part of the body and needs encouragement to “reincorporate” it as a part of own body.
11. Consult with physical therapist regarding active, resistive exercises and client ambulation,
® Individualization program can developed to meet particular needs with deficits in balance, coordination and strength.
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DATE CUES NURSING
DIAGNOSIS
NEED
S
RATIONALE OBJECTIVES
OF CARE
NURSING
INTERVENTIONS
EVALUTAION
D
E
C
E
M
B
E
R
7
2
0
1
Subjectiv
e:
“Nastrok
e siya” as
verbalize
d by the
patient’s
watcher
Objective
:
Speech
abnormal
Ineffective
Cerebral tissue
perfusion r/t
interruption of
blood flow
secondary to
hemorrhage
A
C
T
I
V
I
T
Y
-
E
X
E
R
C
Intake of
Fat and
sodium;
Cigarette
smoking;
Alcoholism,
Imbalanced
nutrition
Vasoconstritio
n
After 2 days of
Nursing
Intervention, the
client will be able
to:
Demonstrate
increased
perfusion as
individually
appropriate such
as warm skin,
strong pulse
present/VS within
1. Determine factors related
to individual situation/cause
for coma/decreased cerebral
perfusion.
R: Influences choice of
interventions.
2. Monitor/document
neurological status
frequently and compare
with baseline.
R:
Assesses trends in level of
consciousness (LOC) and
potential for increased ICP
and is useful in determining
After 2 days of Nursing
interventions, the patient
was able to demonstrate
increased perfusion as
evidenced by:
-warm skin
-strong pulse noted
VS within normal range:
BP=120/80 mm Hg
PR= 80
RR= 20
Temp= 36.9
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2
@
5:00
PM
ity noted
Changes
in motor
response;
extremity
weakness
;
paralysis
Muscle
strength
of
GCS of
I
S
E
P
A
T
T
E
R
N
Intravascular
pressure
resistance to
flow
Scarring of
vessel
Clot formation
normal range. location, extent, and
progression/resolution of
CNS damage.
3.
Monitored vital signs.
R: Fluctuations in pressure
may occur because of
cerebral pressure/injury in
vasomotor area of the brain.
4. Evaluate pupils, noting
size, shape, equality, light
reactivity.
R: Pupil reactions are
regulated by the oculomotor
(III) cranial nerve and are
useful in determining
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VS taken
as noted:
BP=
RR=
PR=
Temp=
Blocks the
vessel in the
brain
CVA
Source:
Textbook of
Medical
Surgical 12th
edition by
Brunner and
whether the brainstem is
intact. Pupil size/equality is
determined by balance
between parasympathetic
and sympathetic enervation.
Response to light reflects
combined function of the
optic (II) and oculomotor
(III) cranial nerves.
5. Document changes in
vision, e.g., reports of
blurred vision, alterations in
visual field/depth
perception.
R:
Specific visual alterations
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Suddhart pg
563
reflect area of brain
involved, indicate safety
concerns, and influence
choice of interventions.
6. Position with head
slightly elevated and in
neutral position.
R: Reduces arterial pressure
by promoting venous
drainage and may improve
cerebral
circulation/perfusion.
7. Maintain bedrest;
provided quiet environment;
Provided rest periods
between care activities,
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limit duration of procedures.
R:
Continual
stimulation/activity can
increase ICP. Absolute rest
and quiet may be needed to
prevent rebleeding in the
case of hemorrhage.
8. Administer medications
as indicated.
R: To promote
pharmacologic treatment
regimen.
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XVII- DISCHARGE PLANNING
(M.E.T.H.O.D.)
Medications
1. Discuss to the significant others all the given home medications such as the brand name,
dosage, contraindications and the purpose of giving such medication.
2. Metropolol 100mg 1 tab BID 6am-6pm
3. Citicoline (NerveCare) 50mg 1 tab TID 6am-1pm-6pm
4. Amlodipine 10 mg 1 tab 6am
5. Irbesartan 30 mg 1 tab OD 6am
6. Atorvastatin 40mg 1 tab OD @ HS 9pm
7. Senna Concentrate 2 tabs OD @ HS 9pm
8. Encourage client to comply with the medications prescribed by the physician.
9. Inform them about the possible side effects that may occur.
10. Encourage patient to take his medications with food or take medicines before meal if/or
needed by medication.
Exercise
1. Instruct to have aerobic exercise should focus on large muscle group conditioning such as
walking, this exercises build endurance, increase independence and decrease
cardiovascular disease, according to the American Heart Association. Aerobic activity
should be performed three to seven days a week, for 20 to 60 minutes.
2. Instruct to have adequate rest.
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3. Encourage client to continue deep breathing exercises to promote circulation of blood and
relaxation
Treatment
1. Educate significant other about the importance of drug compliance for the patients’
condition.
2. Encourage significant other to accept or consider medical advice for the treatment of the
patients’ condition.
Hygiene
1. Educate to perform hand washing before and after meals.
2. Encourage to brush teeth at least three times a day and change brush every three months.
3. Instruct the significant others to maintain a clean and relaxing environment to prevent
patient from acquiring infection and promote healthy environment.
Out patient
1. Advice patient to visit or have a follow up check-up on his schedule day.
2. Instruct significant other to keep periodic appointments with the health care providers for
palliative treatment.
Diet
1. Instruct to eat foods high in fiber also helps lower your cholesterol and reduce your risk
of further strokes. Incorporate at least five fruits and vegetables into your diet each day,
and switch from white bread products to whole grain or whole wheat.
2. Sodium intake should be limited to no more than 1,500 g per day.
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3. Limiting or avoiding foods that are high in trans-fats, saturated fats and cholesterol may
help you lower your cholesterol levels. In a 2,000-calorie meal plan, eat no more than 6
oz. of lean meat, poultry or fish per day. Choose lean cuts of meat, and remove all visible
fat and skin. Broil your meats and pour visible fat off pan-fried foods. Do not use
partially hydrogenated oils, use low-fat or fat-free dairy products, and limit sugary foods
and drinks.
XVIII- PROGNOSIS
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Criteria Poor
(1)
Fair (2) Good
(3)
Justification
Onset of illness X During the onset of attack, the patient didn’t
mind the symptoms he felt until he lost
consciousness and was brought to the
assigned doctor of the event.
Duration of
illness
X The duration of the illness was not too long
since the client was immediately rushed to
the hospital after he was assessed by the
doctor
Precipitating
Factors and
Predisposing
Factors
X
Among the predisposing and precipitating
factors presented which contribute to CVA,
6 of them are present in the patient which
are age, sex, hereditary, hypertension,
increased cholesterol (ldl) and alcohol
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drinking.
Environmental
Factor
X He lives in Bangkal, Davao City. His friends
reported that he lives in a house by himself,
which has adequate space, and that the
environment is peaceful.
Willingness to
take medications/
treatment
X
The patient accepts the need to follow
treatment regimen for his recovery. He is
greatly willing to take his medications and
subject himself to the prescribed treatments.
Age X The patient is 57 years old. Stroke is
considered a disease that generally attacks
elderly persons; And the chance of having a
stroke more than doubles for each 10 years
of life after the age of 55.
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Emotional
Support
X
The patient gets enough emotional support
from his friends. He is well supported by
them and always there to comply with the
treatment of the patient; They regularly visit
him in the hospital.
RATING:
Good: 2.4 – 3.0
Fair: 1.7 – 2.3
Poor: 1.0 – 1.6
COMPUTATION:
Good: 4 x 3 = 12
Fair: 1 x 2 = 2
Poor: 2 x 1 = 2
Total: 16/7 = 2.29 = Fair
XIX- RECOMMENDATION
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To our Client
The potency of the drugs, treatments procedures and therapies given does not rely only to
the health care team, rather, it requires a significant participation on the part of the patient. His
willingness and readiness to understand the purposes of those treatments would be very helpful
for the health care team to provide him of necessary medical and nursing interventions. It would
also be helpful that he verbalize his feelings openly to his friends regarding his concerns to his
condition.
To the Student Nurses
We, the student nurses, are also responsible in providing the basic information of his
disease and its management. Since he has no family in here, in Davao city or anywhere near it,
we should also educate his close friends. In the clinical area, we do not just perform nursing
procedures and administer medications, but , we should serve as health educators. Also, when
performing basic nursing skills in the area, we should be certain and confident enough in
providing treatment to the patient. This case study would also be very helpful on the part of the
student nurses who may handle the same case/disease. The knowledge that we obtained from this
case study could also serve as a basis for the health teachings to the patient.
To the Ateneo de Davao University – School of Nursing
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We would like to recommend the School of Nursing to maintain its high quality of
education. May the high spirits of the clinical instructors be a beacon of morale to the student
nurses, and continue to help, guide, and teach us of the do’s and don’ts of the clinical area. The
School of Nursing should continue to mold the students to be effective in their skills as well as
their knowledge and attitude towards the clients.
XX- REFERENCES
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Book:
1. Estes, M. E. Z. (2010). Health assessment & physical examination. 4th edition.
Developmental Assessment, 4, 89-119.
2. Kozier and Erb’s Fundamentals of nursing, 8th edition 2008 by: Berman, Aubrey, Synder,
Shirlee, Kozier, Barbara & Erb, Glenora
3. Tortora and Derrickson, 9th edition.
4. Nurse’s Pocket Guide 4th Edition by Marilyn Doenges and Mary Frances Moorhouse
5. myDr, 2001. ©Copyright: myDr, UBM Medica Australia, 2000-2011.
6. Theoretical Foundation of Nursing 1st edition by Joy N. Bautista
7. Nursing2006 drug handbook. 26th edition. Lippincott Williams & Wilkins.
8. Nursing2009 student drug handbook. 10th edition. Lippincott Williams & Wilkins.
Internet:
9. http://www.drugs.com/
10. www.myhealth.va.gov/
11. www.stroke.org
12. www.ncbi.nlm.nih.gov
13. www.heart.org
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