DE LA SALLE LIPA

COLLEGE OF NURSING
1962 J.P. Laurel National Highway, Lipa City
Tel. (043)756-5555, 756-2491, 756-2391 loc 270

Date of Assessment: April 5, 2019

Patient History & General Information

Name of Patient: N.M.R. Age: 80 y.o. Gender: Female
Marital Status: Married
Religion: Roman Catholic Date/Time Admitted: March 31, 2019/
8:54AM
Information Provided by: Medical Chart

History of the Present Illness

Chief Complaint: slurring of speech

Summarized Current Illness Episode:

Patient’s baseline status is she walks without assistance and

can do activities of daily living without assistance. History started 1 day
prior to admission at 7AM while having breakfast, patient experienced
generalize body weakness and slurring of speech. Patient is able to
walk without assistance at the time. Few hours prior to admission,
patient stood from a chair and slipped hitting her sacral area to the
floor. Patient had left sided body weakness at the time. No other
symptom noted. No loss of consciousness. Patient then brought to
MMMC for further management.

Adm Dx: Acute cerebrovascular disease, infarct left thalamic

Hypertensive Atherosclerotic Cardiovascular Disease

Vital Signs: Temp: 36.3°C PR: 74 bpm RR: 20 bpm BP: 140/90
mmHg
Height: 5’0” Weight: 43.3 kg

Past Medical History

Family History

(+) Diabetes Mellitus

(+) Heart Disease

Past Medical & Surgical History

(+) Hypertension
(+) Heart Disease
(+) Ectopic Pregnancy

No known surgical history.

Food/Drug Allergies
The patient has no known allergies.
 DE LA SALLE LIPA
COLLEGE OF NURSING
1962 J.P. Laurel National Highway, Lipa City
Tel. (043)756-5555, 756-2491, 756-2391 loc 270

Biophysical, Psychosocial & Functional Assessment

SYSTEM METHOD FINDINGS INTERPRETATION

Follows simple
commands.
Rigidity:
Neurological Inspection Right Arm – 5/5 Normal
Right Leg – 5/5
Left Arm – 5/5
Left Leg – 5/5

No abnormal heart
sounds heard upon
Auscultation
Cardiovascular auscultation Normal
Palpation
HR: 74 bpm
BP: 140/90 mmHg

Normal Breath Sounds

Respiratory Inspection Normal
RR: 20 bpm

Inspection, Normal Bowel sounds

Gastrointestinal Normal
Palpation Non tender

Dry skin. Negative skin

Integumentary Inspection Due to old age
turgor.

Limited range of motion.

Musculoskeletal Inspection Abnormal
Unable of moving freely.

Genitourinary Inspection Able to urinate Normal

.

Reproductive/ Inspection/
No unusual findings Normal
Sexuality Interview

Inspection/ Communicative or
Psycho / Social Normal
Interview interactive
 DE LA SALLE LIPA
COLLEGE OF NURSING
1962 J.P. Laurel National Highway, Lipa City
Tel. (043)756-5555, 756-2491, 756-2391 loc 270

Pain Assessment
Do you have pain? No When: N/A
If yes,
a. Pain location N/A

b. Pain description N/A

c. Pain intensity (Pain Scale) N/A

d. Duration: N/A Frequency: N/A

e. What lessen the pain? N/A

f. What aggravates the pain? N/A

Activities of Daily Living Assessment

ADL Needs
a. Hygiene & Grooming – Well groomed and on patient’s gown
b. Activity – Unable to ambulate
c. Nutrition – On soft diet
d. Toileting – Can urinate but doesn’t defecate yet
e. Sleep – Can sleep at night

Sensory Deficits
a. Vision – No vision defect
b. Hearing – No hearing impairment
c. Speech – Has speech defect
d. Other – None

Assistive Device/s Used None

Cultural Spiritual Assessment

A. Are there any spiritual, traditional, ethnic or cultural practices that need to be part of your client care? None
B. Is there any way the nurse can assist you with your religious / spiritual practice? None
C. Would you like to be visited by the hospital chaplain? No

Assessed By:

AMABEL U. CORTEZ
Staff Nurse
 DE LA SALLE LIPA
COLLEGE OF NURSING
1962 J.P. Laurel National Highway, Lipa City
Tel. (043)756-5555, 756-2491, 756-2391 loc 270

DRUG STUDY
GENERIC NAME BRAND NAME MAJOR DRUG
CATEGORY
Cytidine
Citicoline Neurotropic
diphosphate choline
DRUG ACTION USES SIDE
EFFECTS/ADVERSE
REACTIONS
Used for
Alzheimer's disease
Citicoline is a
and other types of
derivative of choline
dementia, head
and cytidine
trauma,
involved in the  Shock
cerebrovascular
biosynthesis of
disease such as  Hypersensitivity
lecithin. It is
stroke, age-related  Hypotension
claimed to increase
blood flow and
memory loss,  Insomnia
oxygen
Parkinson's  Excitement
disease, attention
consumption in the
deficit-hyperactive
brain.
disorder (ADHD),
and glaucoma.
SIGNIFICANT USUAL DRUG CONTRAINDICATIONS
DRUG DOSE
INTERACTION
 Hypertonia of
parasympathetic
Levodopa 1 gm q8 IV
nervous system
 Meclofenoxate

NURSING MEDICATION MANAGEMENT

ASSESSMENT INTERVENTION

 Monitor blood pressure  Administer with food or

and pulse rate milk to prevent GI upset
 Assess allergic reaction  Reduce dosage if given
like GI disturbances with other antihypertensive
drugs and readjust dosage
gradually as BP responds.
EDUCATION EVALUATION

1. Instruct relative to give In case of persistent intracranial

only prescribed dose.
2. Advise relative to consult
the physician if any
problems occur to the
patient during medication
hemorrhage, the very slow
administration (30 drops/minute)
is recommended because the
administration of larger doses
could provoke an increase of
the cerebral blood flow.