Pamantasan ng Lungsod ng Pasig

Alcalde Jose St., Kapasigan, Pasig City

COLLEGE OF NURSING

CASE STUDY:

“CEREBROVASCULAR
ACCIDENT INFARCT”

Submitted to:

GROUP 2 – BSN III Nightingale

CANLAS, Elaine Joy C.

CASTAÑAS, Arvic Fritz D.R.

CRUZ, Dawn Molly S.

CRUZ, Mylah B.

Submitted by:

Professor Allan David Alcantara

November 2012
 INTRODUCTION

A cerebrovascular accident (CVA), also known as a stroke or brain attack, is a sudden

impairment of cerebral circulation in one or more blood vessels. A CVA interrupts or diminishes oxygen
supply, and often causes serious damage or necrosis in the brain tissues. The sooner the circulation
returns to normal after the CVA, the better chances are for complete recovery. However, about half of
patients who survive a CVA remain permanently disabled and experience a recurrence within weeks,
months, or years.

This case study was all about the CVA infarct/Ischemic in order for us to be familiar about the
disease process, its diagnosis, treatment and etc.

An ischemic stroke is death of an area of brain tissue (cerebral infarction) resulting from an
inadequate supply of blood and oxygen to the brain due to blockage of an artery.

 Ischemic stroke usually results when an artery to the brain is blocked, often by a blood clot or a
fatty deposit due to atherosclerosis.

 Symptoms occur suddenly and may include muscle weakness, paralysis, lost or abnormal
sensation on one side of the body, difficulty speaking, confusion, problems with vision, dizziness,
and loss of balance and coordination.

 Diagnosis is usually based on symptoms and results of a physical examination, imaging tests, and
blood tests.

 Treatment may include drugs to break up blood clots or to make blood less likely to clot and
surgery, followed by rehabilitation.

 About one third of people recover all or most of normal function after an ischemic stroke.

ANATOMY AND PHYSIOLOGY

The Central Nervous System is made up of the brain and spinal cord. The spinal cord transports
sensory and motor information from other parts of the body to the brain. With the spinal cord, the brain
monitors and regulates many unconscious bodily processes such as heart rate and breathing, and
coordinates most voluntary movements. Most important, it is the site of consciousness and of all the
intellectual functions that allow humans to think and create.

This information is carried through impulses from a neuron. Neuron is consists of a nucleus
situated in the cell body, where outgrowths called processes originate from. The main one of these
processes is the axon, which is responsible for carrying outgoing messages from the cell. This axon can
originate from the central nervous system (CNS) and extend all the way to the body's extremities,
providing an efficient highway for messages. Dendrites are smaller secondary processes that grow from
the cell body and axon. 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' (the axon terminal)
connects into a receptor on the target cell and can transmit information between cells.

The brain can be subdivided into several distinct regions: The cerebral hemispheres form the
largest part of the brain, occupying the anterior and middle cranial fossae in the skull and extending
backwards over the tentorium cerebelli. They are made up of the cerebral cortex, the basal ganglia, tracts
of synaptic connections, and the ventricles containing CSF. The Diencephalon includes the thalamus,
hyopthalamus, epithalamus and subthalamus, and forms the central core of the brain. It is surrounded by
the cerebral hemispheres. The Midbrain is located at the junction of the middle and posterior cranial
fossae. The Pons sits in the anterior part of the posterior cranial fossa- the fibres within the structure
connect one cerebral hemisphere with its opposite cerebellar hemisphere.

The Medulla Oblongata is continuous with the spinal cord, and is responsible for automatic control
of the respiratory and cardiovascular systems. The Cerebellum overlies the pons and medulla, extending
beneath the tentorium cerebelli and occupying most of the posterior cranial fossa. It is mainly concerned
with motor functions that regulate muscle tone, coordination, and posture.

Brain regulates many of our activities. The impulses generated and carried by it is an example of
the chemical level of organization of the body. This nerve impulses then regulate the functioning of
tissues, organ and organ system, which permits us to perceive and respond to the world around us and the
changes within us.
 NURSING HEALTH HISTORY

BIOGRAPHIC DATA

Patient’s Name: Patient X Age: 47 y/o Gender: Male

Address: Pasig City
Race: Filipino
Marital Status: Married Occupation: Policeman
Religion: Born Again Christian
Source of Health Care Financing: Wife’s small business

Chief Complaint
“Mga limang araw bago siya dinala sa ospital, napansin ko lagi na lang siyang nasasamid habang
kumakain, at pautal utal ang kanyang sinasabi” as verbalized by the client’s wife.
HEALTH HISTORY

A. History of Present Illness

Patient had CVA 4 years ago with right-sided weakness, maintained with Amlodipine. One day
prior to admission, when his wife arrived home, she noticed that her husband had a right sided upper
extremity weakness and a slurred speech. He was given Nifedipine by his daughter.

B. History of Past Illness

According to the patient’s daughter, he had a TB during his childhood. He also had a gunshot
wound on his left thigh when he was about 30 years old. He was also involved in a bus accident at year
2002, which caused him to have a temporary loss of memory or amnesia. He also had a surgery on his left
leg due to the accident. Currently, he has a pneumonia and hypertension according to his wife.

C. Family History of Illness

The client’s wife and daughter are currently in a good state of health. According to the client’s
daughter, his parents died of heart diseases and were also hypertensive like him.

PAIN ASSESSMENT
The client wasn’t able to say anything about his pain, but he has guarding behaviors when his
swollen lower extremities were being touched.

FUNCTIONAL HEALTH PATTERN

Health Perception/Health Management Pattern

The client wasn’t able to state anything about his perception of his general health, but he was
crying every time his daughter was being asked about something that he can do before but cannot do now.
According to his daughter, the client used to consult a doctor every time he was having problems with his
health. Also, it was said that he was smoking and drinking alcohol during his teenage life, but was able to
get out of it when he was married with his wife.

Nutrition/Metabolic Pattern
According to the client’s daughter and wife, the client was fond of eating about 3 cups of rice
each meal and drinking more than 1500 ml of water a day before he was hospitalized. He also eats pork
and vegetables sometimes. They also mentioned that his favorite drink was Sprite. Now, he was in a
general liquid diet, including jelly ace, soup and etc.

Elimination Pattern
According to the client’s daughter, the client urinates frequently and defecates usually twice a day
before he was hospitalized. Now, the client voids less frequently and defecates about three times a day.
Activity-Exercise Pattern
Before, the client was using a walker, and used to exercise with it for some time. According to
them, he doesn’t want to exercise much because he was afraid of getting fatigued, and then become
hypertensive. He also used to watch television and read a dictionary. Now, he just used to listen to a
music and sleep.

Feeding - 3 Bathing - 2 Toileting - 3 Bed mobility - 3

Dressing - 3 Grooming - 3 General mobility - 3

Note:
Level 0: Full Self-Care
Level 1: Requires use of equipment or device
Level 2: Requires assistance/supervision from another person
Level 3: Require assistance/supervision from another person/device
Level 4: Is dependent and does not participate

Sleep-Rest Pattern
According to his daughter, his sleeps about eight hours every night and takes short naps before he
was hospitalized. He also has no problems sleeping then. Now, he had longer time for sleep since he lies
on bed almost all the time, but was being interrupted from time to time.

Cognitive Pattern
The client easily responds to people he knows but does not respond to strangers. In Glascow-
Coma Scale, his eye response was scored as 4; verbal response was 3; and his motor response was 2.
Thus, he was in GCS-9. The client looks uncomfortable when strangers talk to him.

Self-Perception/Self-Concept Pattern
The client wasn’t able to express much of his own perception subjectively, but it was obvious to
the client that he was not feeling good about himself because he cries whenever some changes about his
abilities are being mentioned.

Role/Relationship Pattern
The client was the breadwinner of his family before, with his job as a policeman. Now, his wife
runs a small business and takes care of him. They had a good relationship since then.

Sexuality/Reproductive Pattern
According to the client’s daughter, her parents are of a long distance relationship before, and so
she was the only daughter of the couple. Therefore, he was not sexually active before and until now. The
client was in Genital Stage according to Sigmund Freud Psychosexual Theory, because he had physical
sexual changes that reawaken his repressed needs. Also, he had direct sexual feelings towards other that
lead to sexual gratification.

Coping-Stress Tolerance Pattern

According to his daughter, he used to pray every time he encounters a problem.
Value-Belief Pattern
According to his daughter, the client values his family and religion. He was an active Born Again
Christian before he was hospitalized.

PRE PHYSICAL EXAMINATION

(November 07, 2010)

Name: Mr. Felix Agoncillo, Jr Age: 46 y/o Gender: Male Status: Married
Address: #9913 Aguinaldo St., Nagpayong 2, Pasig City

Vital Signs: T – 36.5°C P –87 R – 26 BP – 180/100

1. General Survey  Both nares patent

 weak looking  Pinkish mucosa
 conscious and coherent
 GCS=15

2. Skin
 (+) pallor
 (+) dryness 7. Mouth
 (-)dentures
3. Head  Slurring of speech
 Symmetric face  (-) lesions
 Normal hair, and fine distribution  Tongue in midline
 (-)alopecia  (+) caries
 Gums pinkish
4. Eyes  Uvula in midline
 anicteric sclera  Tonsils not inflamed
 lids symmetrical  dry buccal mucosa
 pink palpebral conjunctiva
8. Neck
5. Ears  Trachea in midline
 Pinnae symmetrical  Non-palpable thyroids
 (+) hearing on both sides  Non-palpable cervical lymphnodes
 (-) neck enlargement
6. Nose  Normal ROM
 Symmetrical
 Septum in midline (-) perforation 9. Breast and Axillae
  Equal size, symmetrical 11. Abdomen
 (-) discharge, nipple masses  (-) lesions
 (-) edema, tenderness  (-) rashes
 (-) striae
10. Chest and Lungs  Umbilicus is not bulging
 Symmetrical chest expansion  Flat abdomen
 (-) wheezes  No tenderness
 (-) dullness 12. Back and Extremities
 (-) retraction Peripheral pulses is symmetrical
 Clear breath sounds  Pale nail beds
 (-) clubbing
 Tone normal
 Spine is in the midline
 POST PHYSICAL EXAMINATION
(November 29, 2010)

Name: Mr. Felix Agoncillo, Jr Age: 46 y/o Gender: Male Status: Married
Address: #9913 Aguinaldo St., Nagpayong 2, Pasig City

Vital Signs: T – 36.6°C P –84 R – 26 BP – 130/90

1. General Survey
 Awake
 conscious and coherent 7. Mouth
 On supine position  (-)dentures
 GCS=8  (-) lesions
 Tongue in midline
2. Skin  (+) caries
 Poor skin turgor  Gums pinkish
 Hooked IVF: PNSS 1L x 16°  Uvula in midline
 (-) dryness  Tonsils not inflamed
 dry buccal mucosa
3. Head
 Symmetric face 8. Neck
 Normal hair, and fine distribution  Trachea in midline
 (-)alopecia  Non-palpable thyroids
 Non-palpable cervical lymphnodes
4. Eyes  (-) neck enlargement
 anicteric sclera  Normal ROM
 Lids symmetrical
 Eyes symmetrical 9. Breast and Axillae
 pink palpebral conjunctiva  Equal size, symmetrical
 (-) discharge, nipple masses
5. Ears  (-) edema, tenderness
 Pinnae symmetrical
 (+) hearing on both sides 10. Chest and Lungs
 Symmetrical chest expansion
6. Nose  (+) wheezes
 Symmetrical  (-) dullness
 Septum in midline (-) perforation  (-) retraction
 Both nares patent  (-) murmur
 Pinkish mucosa
11. Abdomen
 (-) lesions
 (-) rashes
 (-) striae
 Umbilicus is not bulging
 Flat abdomen
 No tenderness

12. Back and Extremities

 Pale nail beds
 Peripheral pulses is symmetrical
 (-) clubbing
 Tone normal
 Spine is in the midline
 (-) edema
 Swelling of both lower extremities
 With wound at left foot
 Right sided paralysis
 Dry toe
 With metal inside the thigh and legs
 LABORATORY FINDINGS

Date Laboratory Normal Results Interpretation Indications

Tests Values
11-07-10
Severe Hepatic
3.2-7.1
BUN 2.3 mmol/L decreased Damage,
mmol/L
Malnutrition

Serum 3.6-5.0
3.6 mmol/L normal NA
potassium mmol/L

Prothrombin
10-14 sec. 11.4 sec. normal NA
Time

Activated
partial 27.70-
28.9 sec. normal NA
Thromboplasti 34.10 sec.
n time

135-160
Hemoglobin 145 g/L normal NA
g/L

0.40-0.54
Hematocrit 0.45 g/L normal NA
g/L

150- ADEQUAT
Platelet Count normal NA
400x109/L E

4.50-
WBC count 11.00x109/ 6.8x109/L normal NA
L

Infection,
Neutrophil 0.35-0.65 0.79 increased
ischemic neurosis

Affection of
Lymphocyte 0.20-0.40 0.17 decreased
immune system

Monocyte 0.02-0.08 0.04 normal NA

Prothrombin 10.00-
11.4sec normal NA
Time 14.00sec

Activated 27.70- 28.9sec normal NA

Partial 34.10sec
 Thromboplasti
n Time

Serum Total 0.0-5.2 Coronary Artery

6.3 mmol/L increased
Cholesterol mmol/L Disease

Serum HDL 1.0-1.6 hypertriglyceride

11-10-10 0.8 mmol/L decreased
Cholesterol mmol/L mia

Serum LDL 0.00-3.36 4.97 Coronary Artery

increased
Cholesterol mmol/L mmol/L Disease

135-160
Hemoglobin 149 normal NA
g/L

0.40-0.54
Hematocrit 0.44 normal NA
g/L

150- ADEQUAT
Platelet Count normal NA
400x109/L E
11-17-10
4.50-
WBC Count 11.00x109/ 15.5 increased Infection
L

Infection,
Neutrophil 0.35-0.65 0.89 increased
ischemic neurosis

Affection of
Lymphocyte 0.35-0.65 0.11 decreased
immune system

135-160
Hemoglobin 146.0 normal NA
g/L

0.40-0.54
Hematocrit 0.44 normal NA
g/L

150-
Platelet Count Adequate normal NA
400x109/L
11-22-10
4.50-
WBC Count 11.00x109/ 13.0 increased Infection
L

Infection,
Neutrophil 0.35-0.65 0.87 increased
ischemic neurosis

Affection of
Lymphocyte 0.35-0.65 0.10 decreased
immune system
 Monocyte 0.02-0.08 0.03 normal NA

135-160
11-27-10 Hemoglobin 149.0 normal NA
g/L

0.40-0.54
Hematocrit 0.45 normal NA
g/L

150-
Platelet Count Adequate normal NA
400x109/L

4.50-
WBC Count 11.00x109/ 13.8 increased Infection
L

Infection,
Neutrophil 0.35-0.65 0.89 increased
ischemic neurosis

Affection of
Lymphocyte 0.35-0.65 0.10 decreased
immune system

Monocyte 0.02-0.08 0.02 normal NA

URINE SPECIMEN: 11-10-10

PHYSICAL Specific Gravity – 1.030
Color – yellow CHEMICAL TEST
Transparency – slightly turbid Albumin – negative
pH – 6.5 Sugar - negative

DIAGNOSTIC PROCEDURE

11-07-10

CT scan: (IMPRESSION)

 Acute to subacute non-hemorrhagic infarct, right cerebellar hemisphere.

 Chronic infarct, right subinsular cortex & lentiform nucleus.
 Periventricular ischemic white matter changes, both fronto-parietal lobes.
 Age-related cerebral volume loss.
 Mild atherosclerotic vessel disease.
 Small right sphenoid sinus mucous retention cyst.
  Congested left nasal turbinate.

11-07-10 X-RAY RESULTS

CHEST PAIAP (ADULT)

 The lungs are clear.

 The heart is not enlarged.
 Hemidiaphragms, sinuses and visualized osseous structures are intact.
IMPRESSION:

- NORMAL CHEST

11-19-10 X-RAY RESULTS

CHEST PAIAP (ADULT)

Supine:

 There are suspicious infiltrates in the left apex. Suggest Apicolordotic view.
 Heart & great vessels are within normal size & configuration.
 Other chest structures are unremarkable.

PATHOPHYSIOLOGY OF CVA (STROKE)

Predisposing Factors Precipitating Factors

Smoking, Overweight, Hypertension, High Age, Family History of

Cholesterol Level, Excessive Alcohol CVA, Sex (Men), Race
Consumption,Sedentary Life Style.

Destruction of alpha and

beta cells of the pancreas

Failure to produce insulin

 Production of
excess glucagon

Inc. serum glucose level

Production of
glucose from protein
Glycoprotein cell and fat stores
wall deposits
Impaired immune
function Wasting of lean
(decrease level body mass Fatigue
Small vessel
of morphonuclear
disease
leukocytes) Weight loss
Accelerated Wt. from 80kg to
atherosclerosis
Neuropath
Infection Delayed wound Average BP: 160/110
healing
Furosemide
Symmetri Hypertension
cal loss
Neutrophil - 0.79 of Irbesartan
protectiv Increase LDL levels -
4.97 mmol/L
Numbness Autonomic
and tingling neuropath
Levofloxacin in the
extremities

Dry cracked skin

Thrombus CEREBROVASCULA Occludes a blood Results to blockage of blood

R ACCIDENT vessel in the brain vessel impeding blood flow
Emboli
Hemiparesis (right side)
Decreased Tissue Continuous build p of
perfusion (brain) pressure
Loss of speech

Hemisensory loss
Impaired tissue Cerebral Hypoxia Results to increased
intracranial pressure

Cerebral ischemia Citicoline

Confusionn Altered
Mannitol

Short term
Ischemia
(<10-
15mins)
 Temporary
Deficit

No
permanent
damage

MID CEREBRAL ANTERIOR POSTERIOR VERTEBROBASILA

ARTERY CEREBRAL A. CEREBRAL A. R ARTERY

Hemiparesis (right side) Ataxia

Dysphagi Dysarthia

Aphasi Hemisensory loss

Hemiplegia (left side) Incontinence


Generic Name: Clindamycin
Classification: Anti-infectives, lincosamines
Indication / Action
Treatment of various respiratory,
skin, sinus, and maxillary
infection.
Generic Name: Citicholine
Classification: neurotonics
Indication / Action
-CVD in acute & recovery phase,
symptoms &
signs of cerebral insufficiency
(dizziness,
memory loss, poor
concentration, disorientation,
recent cranial trauma)
Generic Name: Levofloxacin
Classification: Anti-infectives, quinolones
Indication / Action
Dosage & frequency rate
60 mg TIV every 8 hours
Date started: Dec. 20-27
Discontinued by: Dec. 28
Dosage & frequency rate
1gm IV q 12
Date started: Dec. 7-20
Shifted to tablet by Dec. 20-29
Dosage & frequency rate
DRUG STUDY
Contraindication Adverse Reaction Nursing Consideration
Should not be used against: This medication may cause:  Check culture and sensitivity test to
see if this the drug of choice
 Allergy  Abdominal Cramping  Ensure that full course is given to
 Diarrhea  Anorexia help prevent emergence of strain.
 Diarrhea  Provide small frequent meals to
 Vomiting ensure adequate nutrition due to GI
 Confusions upset
 Uncontrollable
Emotions
Contraindication Adverse Reaction Nursing Consideration
-Parasympathetic This medication may cause: - Somazine must not be
administered along with
-hypertonia -shocks, hypersensitivity, medicaments containing
hypotension, insomnia, meclophenoxate
excitement.
Contraindication Adverse Reaction Nursing Consideration
 IM, intrathecal, intraperitoneal,
Infections caused by susceptible 500mg tab OD or SC administration. his medication may cause:  Obtain baseline assessment
strains of microorganisms in  Assess patient for previous
acute maxillary sinusitis, acute  Headache sensitivity reaction
 Dizziness  Monitor for possible drug induced
bacterial exacerbation of chronic
 Insomnia adverse reaction
bronchitis.
 Nausea and Vomiting
ACTION:  Diarrhea

Interferes with DNA

gyrase and topoisomerase IV.
DNA gyrase is an enzyme
needed for replication,
transcription, and repair of
bacterial DNA.

Generic Name: Furosemide

Classification: Diuretics
Indication / Action Dosage & frequency rate Contraindication Adverse Reaction Nursing Consideration

This medication may

Teatment of edema associated with 40mg tad BID x 3days Should not be used against: cause:  Do not confuse Lasix with
congwstive hearrt failiure (CHF), hepatic  Jaundice Lanoxin (a cardiac
cirrhosis, and renal disease, hypertension.  Hearing impairement glycoside).
 Hypersensitivity to  Tinnitus  Monitor Vital signs
Date started: Dec. 17-29 drug  Hypotension especially BP
 Anuria  Pancreatitis  Monitor I&O
 Abdominal pain
ACTION:  Dizziness
 Anemia
Inhibits the reabsorption of sodium and
dichloride in the proximal and distal
tuconstibules as well as the ascending loop
of Henle; this results in the excretion of
sodium,

chloride, and, to a lesser degree, potassium

and bicarbonate ions.
Generic Name: Lactulose
Classification: Laxative
Indication / Action
Constipation, salmonellosis. Treatment of
hepatic encephalopathy.
ACTION:
Causes an influx of fluid in the intestinal
tract by increasing the osmotic pressure
within the intestinal lumen.
Generic Name: Acetylcysteine
Classification: Expectorant
Indication / Action
Treatment for respiratory
affections characterized by thick
and viscous hypersecretion:
acute and chronic bronchitis and
its exacerbation, pulmonary
emphysema and bronchiectasis.
Dosage & frequency rate Contraindication
30cc OD -Patients who require a low
lactose diet.
-Galactosaemia or disaccharide
Date started: Dec. 21-23
deficiency.
-Intestinal obstruction.
Dosage & frequency rate Contraindication
600mg Should not be used against:
 Hypersensitivity
 phenylketonuria
Date started: Dec. 20-28
Adverse Reaction Nursing Consideration
This medication may
cause:  Monitor for possible
adverse GI reaction
 Abdominal  Monitor fluid and
discomfort electrolyte status
 Diarrhea
 Nausea and vomiting
 Flatulence
Adverse Reaction Nursing Consideration
This medication may cause:  Assess patients underlying
condition, cough: type, frequency,
 nausea and vomiting character
 GI symptoms  Assess patient’s respiration and
 Generalized urticaria pulmonary secretions, axarcise
caution on patients with respiratory
accompanied by mild
fever insufficiency and history of
 Hypotension bronchospasm.

Decrease viscosity of respiratory
tract secretions
Generic Name: Salbutamol
Classification: Sympathomimetics
Indication / Action
Bronchospasms chronic
bronchitis, emphysema
Generic Name: Clarithromycin
Classification: Anti-infectives, Macroplides
Indication / Action
Dosage & frequency rate
Should not be used against:
Nebulizer every 8hours
Date started: Dec. 18,22-25
Dosage & frequency rate
Contraindication
This medication may cause:
 Cardiac Disease
 Vascular Disease
 Diabetes
 Hyperthyroidism
 Pregnancy and
Lactation
Contraindication
 Wheezing
 Dyspnea
 stomatitis
Adverse Reaction Nursing Consideration
 Teach the client about the proper
use of prescribe delivery system.
 CNS Stimulation
 GI Upset
 Hypertension
 Bronchospasm
 Sweating Pallor
 Flushing
Adverse Reaction Nursing Consideration
 Treatment of various respiratory,
skin, sinus, and maxillary
infection.
Interfere with protein synthesis
and altering them in bacteria
500mg / tab BID
Date started: Dec. 19-20
Discontinued by: 29( 8am)
Should not be used against: This medication may cause:  Check culture and sensitivity test to
 Allergy  Abdominal Cramping see if this the drug of choice
 to fungal, viral  Anorexia  Monitor renal function decrease
infection  Diarrhea dose as needed
 diarrhea  Vomiting  Ensure that full course is given to
help prevent emergence of strain.
 concomitant use with  Confusions
any of the ff:  Uncontrollable  Provide small frequent meals to
-Cysapride Emotions ensure adequate nutrition due to GI
-Pimozide upset
-Terfenadine

Generic Name: Mannitol

Classification: Diuretic

Indication / Action Dosage & frequency rate Contraindication Adverse Reaction Nursing Consideration
Reduction of elevated Should not be used against: This medication may cause:  assess patients blood ptressure
intracranial pressure,cerebral 100cc TIV q 8  Hypertensive to drug  Dizziness  monitor blood and blood pressure
edema, or increased intraocular  Anuria  Headache regularlty
 Severe pulmonary  fever  check weight
pressure Shifted to 75cc
congestion  monitor CNS symptoms and changes
Elevates blood in mental status
 Pulmonary edema.
plasma,osmolality, resulting in
enhanced flow of water from
tissues including the brain and
cerebrospinal fluid, into
interstitial fluid and plasma.

Generic Name Ceftriaxone

Classification: Anti-infective Ceophalosporin second generation

Indication / Action Dosage & frequency rate Contraindication Adverse Reaction Nursing Consideration

Sepsis, meningitis; abdominal,
Respiratory tract infection
For prophylaxis or infections
Generic Name: Paracetamol
Classification: Antipyretic
Indication / Action
For fever, mild to severe pain.
Should not be used against:
1g IV q 12  Previous
hypersensitivity to aspirin
 Anaphylactic Shock
 Severe renal and
Shifted to Levofloxacin by hepatic failure
Nov.12
Dosage & frequency rate Contraindication
500mg 1 tab Should not be used against:
 Impaired kidney or
liver
 Sensitivity to the drug
This medication may cause:
 GI Upsets
 Hematological changes
 Skin reactions
 Coagulation Disorders
 Phlebitis (IV
administration)
 Headache
 Dizziness
 Renal and gallbladder
precipitation
 Increase In liver
enzyme
 Oliguria
 Increase serum
creatinine
 Anaphylactoid reaction
 Chill
 Cyanosis in infants
Adverse Reaction
This medication may cause:
 Skin rashes and other
allergic reaction.
 GI disturbances.
 Check culture and sensitivity test to
see if this the drug of choice
 Monitor renal function decrease
dose as needed
 Ensure that full course is given to
help prevent emergence of strain.
 Provide small frequent meals to
ensure adequate nutrition due to GI
upset
Nursing Consideration
 Do not take other drugs
containing acetaminophen without
medical advice over dosage and
chronic use can cause hepatic
damage and other toxic effect
Generic Name: Irbesartan

Classification: Cardiovascular drug, Angiotensin II Antagonist

Indication / Action Dosage & frequency rate Contraindication Adverse Reaction Nursing Consideration

Competitively block the 500mg 1 tab Should not be used against: This medication may cause:  Take only as directed. Mat take
angiotension AT1 receptor with or without food
located in vascular smooth  Hypersensitivity  URTI, cough, fatigue,
muscle and the adrenal glands. dyspepsia/heart-burn,
Continued by: Dec. 20-29 diarrhea
 TYPE OF CLASSIFICATION CONTENT MECHANISM OF INDICATION CONTRA- HOW DOSE NURSING
SOLUTION ACTION INDICATION SUPPLIED RESPONSIBILITIES

Plain Normal -Isotonic volume Sodium – 154 Isotonic solution >Replacement & Severe HPN, 1000 ml 1L @ 25 >Monitor pt. frequently for:
Saline expander mmol expands intracellular maintenance of fluid Pulmonary gtts/min. a. Signs of infiltration /
Solution -Electrolyte Chloride – and extracellular space & electrolytes. Edema (20cc/kg of sluggish flow
(PNSS) replacement 154 mmol equally. Uses: intravenous lean body b. Signs of phlebitis /
[0.9% (NS is 9g drips (IV’s), for weight for infection
Sodium NaCl No net fluid shifts occur patients who cannot hypovolemic c. Dwell time of catheter
Chloride dissolved between isotonic take fluids orally and hypotension) and need to be replaced
Solution] in 1 liter solutions because the have developed or are d. Condition of catheter
water; NS solutions are equally in danger of dressing
contains 154 concentrated. developing >Check the level of the IVF.
mEq/L of Na+ dehydration or >Correct solution, medication
and Cl−) It has a slightly higher hypovolemia and volume.
degree of >Check and regulate the drop
osmolarity (i.e. more rate.
solute per litre) than Change the IVF solution if
blood (hence, though it needed.
is said to be isotonic
with blood in clinical
contexts, this is a
technical
inaccuracy).
Nonetheless, the
osmolarity of normal
saline is a pretty close
approximation to the
osmolarity of NaCl in
blood.

IV FLUID STUDY
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

UBJECTIVE: Impaired physical mobility Long term: 1. Assess patient’s ability to Long term:
“ hindi siya makagalaw r/t neuromuscular damage After 4 days of nursing perform ADLs effectively using After 4 days of nursing
simula ng mastoke siya” as
verbalized of her wife.
OBJECTIVE:
Limited ROM
Body weakness
Decreased motor activity
Inability to perform action as
instructed
ASSESSMENT
SUBJECTIVE:
“Napansin ko na lagi nalang
may dinadaing na masakit na
hindi alam ang dahilan.” As
involvement as evidence d
by decreased motor
activity
DIAGNOSIS
Ineffective tissue perfusion
r/t vasoconstriction of
blood vessels
intervention, client will be Functional Level Classification. intervention, client was able to ↑
able to ↑ physical mobility 2. Encourage appropriate use of physical mobility
assistive device such as crutches,
Short term: walker, and wheelchair to
After 8 hrs of nursing increase mobility. Short term:
intervention, client will be 3. Turn and position the patient After 8 hrs of nursing
able to: every 2 hours to promote intervention, client was able to:
1. Participate circulation to all tissues and 1. Participate
in the interventions relieves pressure. in the interventions
rendered by the 4. Perform passive assistive rendered by the
nurse ROM exercises to affected nurse by being active in every activities
2. Demonstrate extremities to promote venous that they have
resumption of return and maintain muscle 2. Demonstrate
activities strength. resumption of
3. Maintain skin integrity activities by performing it
4. Maintain or ↑ muscle 3. Maintain skin integrity
control 4. Maintain or ↑ muscle control
NURSING CARE PLAN
PLANNING INTERVENTION EVALUATION
Long Term: 1. Perform passive range-of- Long Term:
After 8 hours of nursing motion (ROM) exercises to After 8 hours of nursing intervention, the
intervention, the client will be unaffected extremity every 2 to 4 client will be able to maintains optimal
able to maintains optimal hours to prevent venous stasis. tissue perfusion to vital organs, as
verbalized by the patient’s tissue perfusion to vital
wife. organs, as evidenced by
strong peripheral pulses,
normal ABGs, alert LOC, and
OBJECTIVE: absence of chest pain
Confused
Altered LOC Short-Term:
Lethargic After 4 hours of nursing
Increased ICP intervention, the client will be
(BP: 160/100) able to :
(+) facial grimace 1. Participate in passive ROM.
2.Recognize regarding some
measures to prevent increase
ICP.
3. Exercise breathing pattern
during defecation and voiding.
ASSESSMENT DIAGNOSIS PLANNING
SUBJECTIVE: Impaired verbal Long –Term:
“ Napansin ko sa asawa ko na communication After 6 hours of nursing
pautal-utal n magsalita at hindi related to loss of intervention, the
ko na naiintndihan ang facial or oral muscle patient will establish
sinasabi” as verbalized by the tone control. method of
patient”s wife. communication in
which needs can be
expressed.
2. Elevate head of bed 30-45° if
increase ICP.
3. Avoid measures that may
trigger increased ICP such as
straining, and strenuous coughing.
4. Instructed to exhale through the
mouth during voiding or
defecation to decrease strain.
5. Monitor the respiratory
status.
INTERVENTION
1. Provide alternative
methods of communication, like
pictures or visual cues,
gestures or demonstration. R: Provide
communication needs.
2. Talk directly to patient.
Speaking slowly and
directly. Use yes or no
evidenced by strong peripheral pulses,
normal ABGs, alert LOC, and absence of
chest pain
Short-Term:
After 4 hours of nursing intervention, the
client will be able to :
1. Participate in passive ROM.
2.Recognize regarding some measures to
prevent increase ICP.
3. Exercise breathing pattern during
defecation and voiding.
EVALUATION
Long-Term:
After 1 hr. of
nursing
intervention, the
patient was able to
establish method of
communication in
which needs can be
OBJECTIVE:
· Difficulty
producing Short-Term:
speech. After 2 hours of nursing
· Facial paralysis. intervention, the patient will
· Muscle and be able to:
facial tension. 1. Utilize non-verbal cues as
a form of communication.
2. Reduce anxiety.
3. Decrease frustrations.
4. Maximize sense of
independence.
5. Lessen the feeling of
being isolated.
ASSESSMENT DIAGNOSIS PLANNING
Subjective: Impaired skin integrity r/t Long-term:
“Simula nang maparalize siya, physical immobilization as After 8 hours of nursing
wala n siyang gnwa kundi ang evidence by hemiparesis, intervention, the client will
humiga ng humiga.” As limited ROM and dry skin. be able to display
verbalized of the patient’s wife improvement in wound
healing
Objective: Short term:
-Limited ROM After 4 hours of nursing
-Dry cracked skin intervention, the client will
be able to:
question to begin with. R: It reduces
confusion or anxiety
3. Anticipate and provide for patient’s
needs. R: Helpful in decreasing
frustration
4. Place important objects within
reach. R: This maximizes patient’s
sense of independence.
5. Instruct the family members to
give ample time talking to the patient.
R: It is important for family members
to continue talking to the patient to
reduce patients isolation.
INTERVENTION
1. Encourage implementation and
posting of a turning schedule,
restricting time in one position to
2 hours or less.
2. Instructed family to maintain
clean, dry clothes, preferably
cotton fabric (any T- shirt).
3. Encourage the patient to increase
fluid intake to lessen the skin
breakdown.
4. Encourage the client to utilize lift
sheets to reduce shearing forces of
expressed.
Short-Term:
After 2 hours of nursing intervention, the
patient was able to:
1. Utilized non-verbal cues as a form of
communication.
2. Reduce anxiety
3. Decrease frustrations.
4. Maximize sense of independence.
5. Lessen the feeling of being isolated.
EVALUATION
Long-term:
After 8 hours of nursing intervention, the
client was able to display improvement in
wound healing
Short term:
After 4 hours of nursing intervention, the
client was able to:
1. Lessen skin breakdown
2. Reduce shearing forces of the skin
AEB turning the client side to side.

ASSESSMENT
Sujective:
“Sa tuwing pinapakain ko
na siya lagi siyang
nahihirapan lumunok.” As
verbalized of the patient’s
wife.
Objective:
Pt exhibits difficulty
swallowing without
choking.
1. Lessen skin breakdown. the skin
2. Reduce shearing forces of
the skin.
DIAGNOSIS PLANNING INTERVENTION EVALUATION
1. Monitor level of consciousness to Long-Term:
Risk for aspiration r/t Long Term:
prevent risk for aspiration. After 2 hours of nursing intervention
impaired swallowing After 8 hours of nursing
2. Assess gag and cough reflex to the client was able to:
intervention, the client will be
prevent risk for aspiration. Maintain a patent airway and clear
able to maintain a patent airway
3. Encourage patient to chew lung sounds by discharge.
and clear lung sounds
thoroughly and eat slowly during
meals. Instruct patient not to talk Short term:
Short term:
while eating. After 4 hours of nursing intervention,
After 4 hours of nursing
4. Provide oral care after meals. the client was able to:
intervention, the client will be
5. 1. prevent from aspiration
able to:
2. position properly during eating
1. prevent from aspiration
2. position properly during
eating
 COURSE IN THE WARD

History of Past Illness

According to the patient’s daughter, he had a TB during his childhood. He also had a gunshot
wound on his left thigh when he was about 30 years old. He was also involved in a bus accident at year
2002, which caused him to have a temporary loss of memory or amnesia. He also had a surgery on his left
leg due to the accident. Currently, he has pneumonia and his wife.

History of Present Illness

Patient had CVA 4 years ago with right sided weakness, maintained with Amlodipine. One day
prior to admission, when his wife arrived home, she noticed that her husband had a right sided upper
extremity weakness and a slurred speech. He was given Nifedipine by his daughter.

ER (11/07/10)

Patient X was admitted to the ED last November 07, 2010 at 12:25 pm. Chief complaint was
dizziness; slurring of speech. Patient has normocephalic head, pink palpebral conjunctiva, anicteric sclera,
rough,dry skin. Symmetrical lung expansion was noted along with adynamic precordium. Some part of the
extemitites is swelling. Patient has hypertension in the past. Family also have hypertension. Patient is an
alcohol drinker along smoking. The working diagnosis for him was CVA infarct. Doctor ordered IVF of
PNSS 1L to run for 16 hours, that the patient be admitted to ED, O2 via NC at 4 lpm. The doctor also
ordered for some lab workups like CBG, CXR, UA, Na, K, BUN, Crea, Main CT scan. The patient was
instructed to be on NPO temporarily and on HBR position. V/S was to be monitored every 1 hour along
with his I&O. patient had the ff. medications: Citicholine 2gm TIV now then 1gm BID, Ranitidine 50mg
IV, Aspirin 80mg 1tab, 1tab to be chewed and swallowed, Ceftriaxone 1gm IV q12 ANST, Citicholine
1gm IV q 12, Lactulose 30cc q HS, Irbesartan 150g 1 tab OD, Furosemide 40g IV now, Clarithromycin
500mg.
The doctor also ordered that the patient be admitted to the MMW in service of Dra. Lim/ Dr.
Deleon/ Dr. teodocio. Doctor asked that a secured consent to admission and management. NGT was
ordered to be inserted and start OF feeding at 1600 kcal in 6 divided using nutren optimum at 3:50pm
MMW (11/08/10)

Patient was admitted to the male medicine ward accorging to the doctor’s order . he was awake and
coherent, on MHBR. Patient’s family refused NGT insertion with consent signed and secured. Prescribed
medications were followed accordingly. He was put on clear liquid diet. IVF was maintained and O2
support via NC at 3lpm. Instructed the client to have LSLF diet as ordered.

(11/09/10 – 11/29/10)

Care and management is continued to the patient who have ongoing IVF of PNSS 1L to run for 10
hrs.. Follow up of CXR, CT scan was prompted. Client was ordered to be turned from side to side every 2
hrs. and be placed on MHBR. Client was instructed to have LSLF diet as ordered, mannitol was ordered to
be decreased to 45cc TIV every12 hrs. for 2 doses then discontinue(11/10/10). For relay CXR, CT scan
result and kept rested (11/11/10). Doctor ordered to Shift cefriaxone to levofloxacin 1 tab OD and
clindamycin 300mg 1 cap QID (11/12/10). Increase irbesartan to 300mg 1 tab OD (11/13/10). Nebulization
instructed. Similar interventions were carried out through the days.

NURSING THEORY
 This study utilized the Goal Attainment Theory which was first introduced by Imogene King in
the early 1960’s. The essence of goal attainment theory is that the nurse and the patient work together to
define and reach goals that they set together. Through communication, they set goals and agree on how to
achieve those goals (King, 1981). Nursing involves caring for the human being and views the goal of
health as adjusting to the stressors in the internal and external environments (Boyd, 2005).

First, a definition of the three (3) dynamic interacting systems will be discussed in order to gain
an understanding of what is expected during the hospital stay. Afterwards nursing activities and goals
which are necessary will be integrated regarding the said interacting system.

Personal System consists of variables that are unique to each person (nurse, patients, etc.). It
includes perception, self, growth and development, body image, space, learning and time.

In this interacting system, the nurse will be able to communicate with patient to obtain
information regarding self-perception, body image and other relevant information of all the components
of his personal self. In the nursing process, during assessment, the patient and the nurse must be able to
interact and begins in communicating.

According to the patient’s wife, before he was hospitalized in Pasig City General Hospital, he
wanted to continue his activities of daily living right after his recovery. She added that Mr. X wanted to
ambulate again for him to help his family financially and be able to support his only daughter. The nurse
must be able to encourage Mr. X to perform passive ROM to prevent venous stasis. In line with this, Mr.
X goal was to ambulate again. The nurse must encourage utilizing mobility assistive device such as
walker, crutches and etc., to return from previous activities of daily living. Empowerment to the client
must be done in order to reach the goal of Mr. X.

Interpersonal System includes variables that exist when an interaction between persons occur
(nurse-patient, patient-relative, etc.). Concepts related to interpersonal systems are interaction,
communication, transactions, role and stress.

Upon having communication with the client, interpersonal system will then exist wherein during
the planning, transactions and client’s participation are encouraged in decision making by the means to
achieve the goals. If a goal has been set, a transaction is said to have occurred. This is where the nurse
and the patient also decide on way to work toward the goal that has been decided upon, and put into
action the plan that has been agreed upon. Transaction will occur during implementation phase; Imogene
King believes that the main function of nursing is to increase or to restore the health of the patient to re-
establish the normal activities of daily living.

In this situation, Mr. X chief complaint was slurring of speech. Both the client and the nurse had a
problem in terms of communication. Although Mr. X can comprehend the words that the nurse says to
him, but he was hard to express on what he wanted to say or to talk about. So, nurses must be focus on
communication of the patient. The goal here was to communicate with others. The nurse must use non-
verbal cues in order to convey messages to the receiver.
 Social System occurs when socially acceptable roles and boundaries are accepted and followed as
a mechanism to regulate interactions. It includes the organization, authority, power, status, and the
decision making.

This is where Mr. X will realize that he is a patient who permitted himself to be in this institution
that has the same goal as what he wants. The patient wants to get well that is why he is in a caring
institution (Pasig City General Hospital) wherein he has to follow certain rules as well as to communicate
his needs to the healthcare team.

DISCHARGE PLANNING

Medication

 Discuss with the patient the need to comply with home medication. This will help the family and
the patient to know the importance and advantage in complying treatment regimen.
 Explain with them the advantages and disadvantages of strict compliance of treatment regimen.
This will ensure and encourage the patient that taking medications will help treat and prevent
recurrence of the disease and for faster recovery
 Instruct the patient and whether the right time, right medication, right dosage, and right routes as
ordered by the physician. This will avoid confusion of the proper drugs that would be taken by
the patient.
 Instruct the patient not to skip taking medications and complete the whole course of medication.
This will help for an effective action and compliance of the medications and for faster recovery.
 Remind the patient about the importance of taking consideration of the foods and other drugs that
is contraindicated while taking the medications. This will prevent further complications and
unnecessary effects to the patient.
 Instruct and warn patients and significant other about the possible effects and adverse reactions
that may occur brought about by taking the medications.
 Remind them to take the drugs properly and taking note of the expiration date before taking the
medication. This will ensure good compliance of the medications to be taken and to prevent
accident poisoning.
 Instruct the patient and the family to properly store and handle the medications so as to let
children accidentally get hold of it. This will prevent accidents of drug poisoning.
Exercise/Environment

 Encourage the client to exercise ROM.

Treatment

 Explain the purpose of treatment and why it is continued at home. This will help the patient and
family to be oriented about the treatment and this will help him understand about the importance
of taking the prescribed drugs for faster recovery in the disease process. Also, to make them
aware that the treatment is not only done in the hospital but it should be continued at home.
 Direct and instruct the patient and the family to give medication or assist the patient according to
the medication regimen. Giving the medication and assisting the patient accordingly will have
good compliance of the medications and will give sufficient effect to the patient’s condition.
 Emphasize the importance of recognizing any sign of unusuality. To give appropriate
intervention.

Health Teaching/Hygiene

 Encourage and advice the patient and family members practice proper handwashing before and
after eating. Proper handwashing will prevent the spread of infection.
 Instruct patient to do activities of daily living if the client is able to do. To promote good health
and prevent infection. It also increases the sense of wellness, which is very much needed in the
therapeutic process.

Out-patient Referral

 Encourage the patient and the family to have regular check-up with their physician. To monitor
health status and conditions. This will help recognize any alterations in the body.
 Advice patient and family to follow doctor’s order comply with the doctor’s advice and follow
what is stated in the written discharge instruction. Following the doctor’s order and complying
will help achieve the success of the treatment coarse and will help for the immediate recovery of
the patient.
 Encourage the patient and the family to immediately report any unusualities regarding the
patient’s condition. To immediately give enough attention to treat the said complaint.

Diet

 Encourage the client to be on low salt low fat. To prevent having elevated blood pressure.