DONA REMEDIOS TRINIDAD ROMUALDEZ MEDICAL FOUNDATION, INC.

COLLEGE OF NURSING
TACLOBAN CITY

CASE PRESENTATION ON PATIENT

WITH CVD BLEED, LEFT
CAPSULOGANGLIONIC (70CC)

PRESENTED BY:

Badar, Lucy Estrellita E.

Cua, Bianca Jane A.
Dacillo, Gaille Lyn A.
Dames, Jan Remedios B.
De Guzman, Sheila Mae C.
Descartin, Danyssa Bea M.
Dioso, Hazel Jill I.
Ferreras, Czantelle Neil M.
Fortuno, Ira Fe
Garcia, Erica P.
Garcia, Khrizsha Van Marie V.
Geraldo, Paula Bianca D.

CLINICAL GROUP D – BATCH SAPPHIRE

January 30-31, 2023

 INTRODUCTION

GENERAL OBJECTIVE

After the presentation and discussion of the case, the student’s knowledge of the specific disease process
of CVD Bleed; Left Capsuloganglionic, will be enhanced and further understood through comprehensive,
detailed, and accurate history taking, 1st and 2nd Levels of Assessment, interpretation of laboratory tests and
results, explanation of the pathophysiology through a schematic diagram, and the different treatment modalities
given to the patient.

SPECIFIC OBJECTIVE

• To accurately present the patient’s biographical profile along with a comprehensive nursing health
history
• To discuss the related anatomy and physiology of Cardiovascular Disease
• To interpret the different laboratory tests and results and other specific tests done to the client.
• To explain the pathophysiology of the disease using a schematic diagram
• To present the pharmacologic drugs given and to relate to the disease condition.
• To identify different nursing diagnoses, appropriate to the client’s condition
• To implement independent, dependent and collaborative nursing interventions suitable on the client’s
condition.
BACKGROUND OF THE DISORDER
What is Cerebrovascular Accident?
Also known as stroke, an umbrella term that refers to a functional abnormality of the central nervous
system that occurs when the blood supply to the brain is disrupted. A stroke is when blood flow to a part of
your brain is stopped either by a blockage or the rupture of a blood vessel. There are important signs of a
stroke that you should be aware of and watch out for. Currently, stroke is the second leading cause of
mortality in the Philippines while it is considered the primary cerebrovascular in the United States and while it
dropped from the fourth to fifth leading cause of death, it is still leading cause of serious, long-term disability.

Stroke Symptoms
Warning signs may include some or all of the following symptoms, which are usually sudden:
• Dizziness, nausea, or vomiting
• Unusually severe headache
• Confusion, disorientation or memory loss
• Numbness, weakness in an arm, leg or the face, especially on one side
• Abnormal or slurred speech
• Difficulty with comprehension
• Loss of vision or difficulty seeing
• Loss of balance, coordination or the ability to walk

Remembering the acronym “FAST” helps people recognize the most common symptoms of stroke:
• F—Face: Ask the person to smile. Does one side of the face droop?
• A—Arms: Ask the person to raise both arms. Does one arm drift downward?
• S—Speech: Ask the person to repeat a simple phrase. Is the speech slurred or strange?
• T—Time: If you see any of these signs, call:

TACRU: 09064572852
EVMC (Cabalawan): 09173229585

EVMC (Magsaysay): 09273732694

TACLOBAN SAFE CITY: 09778080911

What causes stroke?

There are two main causes of stroke: a blocked artery (ischemic stroke) or leaking or bursting of a
blood vessel (hemorrhagic stroke). Some people may have only a temporary disruption of blood flow to the
brain, known as a transient ischemic attack (TIA), that doesn't cause lasting symptoms.
Ischemic Stroke
An ischemic stroke happens when a blood clot blocks a vessel carrying blood to the brain. The blood is unable
to reach cells in the brain, and they begin to die.

Hemorrhagic Stroke
A hemorrhagic stroke occurs when blood leaks from a burst, torn, or unstable blood vessel into the brain
tissue. The buildup of blood can create swelling and pressure, which can lead to brain damage.

Many basal ganglia strokes are hemorrhagic strokes that result from high blood pressure.

Transient Ischemic Attack (TIA)

Also known as “mini-strokes,” a TIA occurs when there is a blockage of blood flow to the brain for a short time,
usually no longer than 5 minutes. It can be a warning sign that a more severe type of stroke will happen. As
many as 10–15% of people who have a TIA experience a major stroke within the next 3 months.

Risk Factors
Certain factors can raise your risk of a stroke. The major risk factors include:
• High blood pressure. This is the primary risk factor for a stroke.
• Diabetes.
• Heart diseases. Atrial fibrillation and other heart diseases can cause blood clots that lead to stroke.
• Smoking. When you smoke, you damage your blood vessels and raise your blood pressure.
• A personal or family history of stroke or TIA.
• Age. Your risk of stroke increases as you get older.
• Race and ethnicity. African Americans have a higher risk of stroke.

There are also other factors that are linked to a higher risk of stroke, such as:
• Alcohol and illegal drug use
• Not getting enough physical activity
• High cholesterol
• Unhealthy diet
• Having obesity

Complications
• Aspiration pneumonia
• Dysphagia in 25% to 50% of patients after stroke
• Spasticity, contractures
• Deep vein thrombosis, pulmonary embolism
• Brain stem herniation

What is Glasgow Coma Scale?

The Glasgow Coma Scale (GCS) is the most common scoring system used to describe the level of
consciousness in a person following a traumatic brain injury. Basically, it is used to help gauge the severity of
an acute brain injury. The test is simple, reliable, and correlates well with outcome following severe brain
injury.
What is High Blood Pressure?
High blood pressure, also called hypertension, is blood pressure that is higher than normal. Your blood
pressure changes throughout the day based on your activities. Having blood pressure measures consistently
above normal may result in a diagnosis of high blood pressure (or hypertension).

The higher your blood pressure levels, the more risk you have for other health problems, such as heart
disease, heart attack, and stroke.

Symptoms of high blood pressure:

• Blurry or double vision.
• Lightheadedness/Fainting.
• Fatigue.
• Headache.
• Heart palpitations.
• Nosebleeds.
• Shortness of breath.
• Nausea and/or vomiting
Two Main Types of Hypertension
1. Primary Hypertension
- Also known as essential hypertension.
- High blood pressure that is not related to another medical condition.
- This type of hypertension is diagnosed after a doctor notice that your blood pressure is high on three
or more visits and eliminates all other causes of hypertension.
- Usually, people with essential hypertension have no symptoms, but you may experience frequent
headaches, tiredness, dizziness, or nose bleeds.
- Although the cause is unknown, researchers do know that obesity, smoking, alcohol, diet, and heredity
all play a role in essential hypertension.

2. Secondary Hypertension
- The most common cause of secondary hypertension is an abnormality in the arteries supplying blood
to the kidneys.
- Other causes include airway obstruction during sleep, diseases and tumors of the adrenal glands,
hormone abnormalities, thyroid disease, and too much salt or alcohol in the diet.
- Drugs can cause secondary hypertension, including over-the-counter medications such as ibuprofen
(Motrin, Advil, and others) and pseudoephedrine (Afrin, Sudafed, and others).
- The good news is that if the cause is found, hypertension can often be controlled.

How can high blood pressure cause stroke?

High blood pressure can cause the arteries that supply blood and oxygen to the brain to burst or be
blocked, causing a stroke. Brain cells die during a stroke because they do not get enough oxygen. Stroke can
cause serious disabilities in speech, movement, and other basic activities.
ANATOMY OF THE BRAIN
Overview
The brain is an amazing three-pound organ that controls all functions of the body, interprets information from
the outside world, and embodies the essence of the mind and soul. Intelligence, creativity, emotion, and
memory are a few of the many things governed by the brain. Protected within the skull, the brain is composed
of the cerebrum, cerebellum, and brainstem.
The brain receives information through our five senses: sight, smell, touch, taste, and hearing - often many at
one time. It assembles the messages in a way that has meaning for us, and can store that information in our
memory. The brain controls our thoughts, memory and speech, movement of the arms and legs, and the function
of many organs within our body.
The central nervous system (CNS) is composed of the brain and spinal cord. The peripheral nervous system
(PNS) is composed of spinal nerves that branch from the spinal cord and cranial nerves that branch from the
brain.
The brain is composed of the cerebrum, cerebellum, and brainstem.

1. Cerebrum: is the largest part of the brain and is composed of right and left hemispheres. It performs
higher functions like interpreting touch, vision and hearing, as well as speech, reasoning, emotions,
learning, and fine control of movement.
2. Cerebellum: is located under the cerebrum. Its function is to coordinate muscle movements, maintain
posture, and balance.
3. Brainstem: acts as a relay center connecting the cerebrum and cerebellum to the spinal cord. It performs
many automatic functions such as breathing, heart rate, body temperature, wake and sleep cycles,
digestion, sneezing, coughing, vomiting, and swallowing.

Right brain – left brain

The cerebrum is divided into two halves: the right and left hemispheres (Fig. 2) They are joined by a bundle of
fibers called the corpus callosum that transmits messages from one side to the other. Each hemisphere controls
the opposite side of the body. If a stroke occurs on the right side of the brain, your left arm or leg may be weak
or paralyzed. Not all functions of the hemispheres are shared. In general, the left hemisphere controls speech,
comprehension, arithmetic, and writing. The right hemisphere controls creativity, spatial ability, artistic, and
musical skills. The left hemisphere is dominant in hand use and language in about 92% of people

Lobes of the brain

The cerebral hemispheres have distinct fissures, which divide the brain into lobes. Each hemisphere has
4 lobes: frontal, temporal, parietal, and occipital. Each lobe may be divided, once again, into areas that serve
very specific functions. It’s important to understand that each lobe of the brain does not function alone. There
are very complex relationships between the lobes of the brain and between the right and left hemispheres.

Frontal lobe
• Personality, behavior, emotions
• Judgment, planning, problem solving
• Speech: speaking and writing (Broca’s area)
• Body movement (motor strip)
• Intelligence, concentration, self-awareness

Parietal lobe
• Interprets language, words
• Sense of touch, pain, temperature (sensory strip)
• Interprets signals from vision, hearing, motor, sensory and memory
• Spatial and visual perception

Occipital lobe
• Interprets vision (color, light, movement)

Temporal lobe
• Understanding language (Wernicke’s area)
• Memory
• Hearing
• Sequencing and organization
EFFECTS OF STROKE IN THE BRAIN

What are the effects of stroke?

The effects of stroke vary from person to person based on the type, severity, location, and number of
strokes. The brain is very complex. Each area of the brain is responsible for a specific function or ability. When
an area of the brain is damaged from a stroke, the loss of normal function of part of the body may occur. This
may result in a disability.

The brain is divided into 3 main areas:

• Cerebrum (right and left sides or hemispheres)
• Cerebellum (top and front of the brain)
• Brainstem (base of the brain)

Depending on which of these regions of the brain the stroke occurs, the effects may be very different.

What effects can be seen with a stroke in the cerebrum?

The cerebrum is the part of the brain that occupies the top and front portions of the skull. It controls movement
and sensation, speech, thinking, reasoning, memory, vision, and emotions. The cerebrum is divided into the
right and left sides, or hemispheres. Depending on the area and side of the cerebrum affected by the stroke, any,
or all, of these functions may be impaired:

• Movement and sensation

• Speech and language
• Eating and swallowing
• Vision
• Cognitive (thinking, reasoning, judgment, and memory) ability
• Perception and orientation to surroundings
• Self-care ability
• Bowel and bladder control
• Emotional control
• Sexual ability

In addition to these general effects, some specific impairments may occur when a particular area of the
cerebrum is damaged.

The effects of a right hemisphere stroke may include:

• Left-sided weakness or paralysis and sensory impairment
• Denial of paralysis or impairment and reduced insight into the problems created by the stroke (this is
called "left neglect")
• Visual problems, including an inability to see the left visual field of each eye
• Spatial problems with depth perception or directions, such as up or down and front or back
• Inability to localize or recognize body parts
• Inability to understand maps and find objects, such as clothing or toiletry items
• Memory problems
• Behavioral changes, such as lack of concern about situations, impulsivity, inappropriateness, and
depression

The effects of a left hemisphere stroke may include:

 • Right-sided weakness or paralysis and sensory impairment
• Problems with speech and understanding language (aphasia)
• Visual problems, including the inability to see the right visual field of each eye
• Impaired ability to do math or to organize, reason, and analyze items
• Behavioral changes, such as depression, cautiousness, and hesitancy
• Impaired ability to read, write, and learn new information
• Memory problems

What effects can be seen with a stroke in the cerebellum?

The cerebellum is located beneath and behind the cerebrum towards the back of the skull. It receives sensory
information from the body through the spinal cord. It helps coordinate muscle action and control, fine
movement, coordination, and balance. Although strokes are less common in the cerebellum area, the effects can
be severe. Four common effects of strokes in the cerebellum include:
• Inability to walk and problems with coordination and balance (ataxia)
• Dizziness
• Headache
• Nausea and vomiting

What effects can be seen with a stroke in the brainstem?

The brainstem is located at the base of the brain right above the spinal cord. Many of the body's vital "life-
support" functions such as heartbeat, blood pressure, and breathing are controlled by the brainstem. It also helps
control the main nerves involved with eye movement, hearing, speech, chewing, and swallowing. Some
common effects of a stroke in the brainstem include problems with:
• Breathing and heart functions
• Body temperature control
• Balance and coordination
• Weakness or paralysis
• Chewing, swallowing, and speaking
• Vision
• Coma
• Unfortunately, death is possible with brainstem strokes.

CONTRALATERAL HEMIPLEGIA (patient manifested this type of hemiplegia)

• which means opposite side paralysis

IPSILATERAL HEMIPLEGIA
• When you have hemiplegia on the same side

STROKE SCALE
• The National Institutes of Health Stroke Scale (NIHSS) is a systematic, quantitative assessment tool to
measure stroke-related neurological deficit. In clinical practice it can be used to evaluate and document
neurological status in acute stroke patients, determine appropriate treatment and assist in standardizing
communication between healthcare practitioners. The NIHSS has been shown to be a predictor of both
short- and long-term outcomes of stroke patients.
• The NIHSS is designed to be a simple tool that can be administered in less than 10 minutes by
physicians, nurses or therapists
• The NIHSS is a 15-item neurological examination stroke scale used to evaluate the effect of acute
cerebral infarction on the levels of consciousness, language, neglect, visual-field loss, extraocular
movement, motor strength, ataxia, dysarthria, and sensory loss. A trained observer rates the patent’s
 ability to answer questions and perform activities, without coaching and without making assumptions
about what the patient can do.
• Ratings for each item are scored on a 3- to 5-point scale, with 0 as normal, and there is an allowance for
untestable items. Scores range from 0 to 42, with higher scores indicating greater severity.
• Stroke severity may be stratified on the basis of NIHSS scores as follows:[6]

➢ Very Severe: >25

➢ Severe: 15 – 24
➢ Mild to Moderately Severe: 5 – 14
➢ Mild: 1 – 5'

SIGNS AND SYMPTOMS

MANIFESTED BY THE CLIENT
Right-sided weakness Injury to the left side of the brain, which controls
language and speaking which can result in right sided
weakness.
Aphasia (receptive) Most common cause of aphasia is brain damage
resulting from a stroke. The blockage or rupture of a
blood vessel in the brain.
Altered intellectual ability In stroke, reduced perfusion of the brain with hypoxia
which deranges neurotransmission may be the cause.
Dysphagia A stroke can affect the muscles we use to eat and
swallow. These muscles may include your lips, your
tongue, and the muscles in your throat. Some
swallowing problems are easy to see like drooling,
coughing or choking.

PATIENT’S PROFILE

GENERAL DATA or DEMOGRAPHIC PROFILE

This is a case of Into, Rene, a 43-year-old male, Filipino, Roman Catholic and a resident of Brgy.
Bagacay, Tacloban City. He was born on June 20, 1979, in the same city. He currently lives with his partner
named Cherrylou Inot. They have 5 children. He is the third child among seven children of Mr. Concordio Inot
and Mrs. Melita Inot. He is a highschool graduate. He works as a helper in the market currently.

CHIEF COMPLAINT

Right sided body weakness.

HISTORY OF PRESENT ILLNESS

Patient was last seen apparently well at around 9pm on August 30, 2022. Several minutes later, the
patient had a sudden onset of right sided body weakness with slurring of speech. Patient was immediately
brought to EVMC for further evaluation and management. Hence, admission.
The patient was diagnosed with hypertension last 2018. The medication prescribed to him was
Telmisartan 40 mg 1 tab after breakfast. He doesn’t take it regularly. “Danay di nainom kay nainom naman hin
herbal sugad hin pansit-pansitan ngan guyabano leaves. Gin iinom ini niya kun nasakit iya tiil. Kun nagkaka-
mayada kwarta, danay nainom hiya hito na Telmisartan,” as verbalized by the wife. The patient frequently
experiences pain and weakness of the lower extremities.
PAST MEDICAL HISTORY

Patient did not have any problems at birth. The illnesses he had during childhood were just cough, colds,
and fever. He has no known food or drug allergies. The only immunization he had was COVID vaccine, he
completed two doses of Pfizer vaccine. The wife cannot recall other immunizations he had. He hasn't had any
surgeries nor accidents in the past. On year 2018 patient was diagnosed of hypertension he was prescribed a
maintenance medication of Telmisartan 40 mg 1 tab after breakfast. This is the first time that he was admitted.

FAMILY HEALTH HISTORY

On the client's paternal side, there is history of hypertension. His first cousin died due to stroke and
another cousin from the same side has a kidney disease. On the client's maternal side, there is also a history of
hypertension. Other than what was previously mentioned, SO negates any other heredo-familial diseases on
both the maternal and paternal side.

PSYCHOSOCIAL HISTORY

Patient is 43 years old male, born on June 20, 1979 and was raised in Brgy. Bagacay, Tacloban City. He
is the 3rd among 7 siblings in his family. He currently resides still at the same city with his wife and 5 children.
He finished his education until high school. He was working at the market during weekdays and has day-offs
during weekends. Patient does not smoke and does not use illicit drugs. He drinks alcoholic beverages an
average of three glasses each month. With regards to Erik Erikson's theory of psychosocial development, patient
is in the stage of Generativity versus stagnation (between the approximate ages of 40 and 65) During this stage,
middle-aged adults strive to create or nurture things that will outlast them, often by parenting children or
fostering positive changes that benefit others. Contributing to society and doing things to promote future
generations are important needs at the generativity versus stagnation stage of development.

GORDON’S 11 FUNCTIONAL HEALTH PATTERNS

1. HEALTH PERCEPTION AND HEALTH MANAGEMENT PATTERN

Before: “Maupay man eto hiya mag ataman it iya kalugaringon, mahirot eto hiya kay nadire nagusto
magkasakit kay mahal naman yana it mga medisina” as verbalized by wife

Now: “Gin bubuligan ko nala ini hiya kada adlaw pag stretch ngan pag masahe haiya” as verbalized by wife

2. NUTRITION AND METABOLISM PATTERN

Before: His usual meal is paksiw, tinola, and vegetables. He eats approximately 2 cups of rice every meal. He
eats thrice a day with snacks in between. His usual snack is bread. He drinks tuba for about three glasses each
month. He doesn’t smoke.

Now: As of September, He is on NPO from the day he was admitted.

3. ELIMINATION PATTERN

Before: He has no problem with urination and defecation. He urinates 7 times a day and defecates once a day,
every day.
Now: The patient is in diaper; the wife cannot tell how many times in a day he urinates but he changes his
diaper 3 times a day. He hasn’t been able to defecate since the day he was admitted. (5 days)

4. ACTIVITY EXERCISE PATTERN

Before: He likes to have his morning walk. He also does some stretching before he starts his work. He watches
TV in his leisure time.

Now: As of September, He just mostly lie on his bed. His wife helps him to do passive ROM exercises on his
bed and he is not able to do any ADL’s. He is still experiencing right side body weakness.

5. COGNITIVE-PERCEPTUAL PATTERN

Before: He doesn’t have sensory problems.

Now: As of September, He is lethargic. Current GCS score of 11 (September 4 2022). Aphasia and dysphagia
were noted.

6. SLEEP-REST PATTERN

Before: He usually has 7-8 hours of sleep at night. He sleeps around 9 or 10 o’clock in the evening and wakes
up at around 4 or 5 o’clock in the morning. He sometimes naps in the afternoon after lunch. He doesn’t have
problem in sleeping.

Now: As of September, His sleeping schedule is irregular. He usually sleeps around 8PM and he wakes up
around 11 o’clock in the evening. He sleeps again at 1AM and wakes up at 4 o’clock in the morning.

7. SELF-PERCEPTION PATTERN

Before: He is a workaholic person. He will do everything for his family.

Now: As of September, Patient can no longer communicate verbally but incomprehensible sounds were noted.

8. ROLE-RELATIONSHIP PATTERN

Before: “Para ha akon, gingagampanan niya hin maupay an iya pagigin padre de pamilya,” as verbalized by the
SO. He has a good relationship with his family. “Diri maiiwasan it pag-aaway, kay normal man la ito, pero
nasosolbar man gihap,” as verbalized by the wife

Now: As of September, He still has a good relationship with his family. But he can no longer perform his role
as a father.

9. SEXUAL REPRODUCTIVE PATTERN

Before: There is no noted problem related with his reproductive system. He still engages in sexual activity.
They don’t use any contraceptive method with his wife.

Now: As of September, There is no noted problem related with his reproductive system

10. COPING AND STRESS TOLERANCE PATTERN

Before: He doesn’t get stressed easily but when problems come, he goes to his siblings for him to express his
feelings.

Now: As of September, He easily gets irritated now especially when he has a headache.

11. VALUES AND BELIEF PATTERN

Before: He is a Roman Catholic. He frequently attends Sunday masses. He prays before going to bed.

Now: “Kun nangangadi ako gin yayaknan ko hiya kay bisan dire hiya nakakastorya, makakabati la gihap hiya
haakon nga nangangadi tas gin bubutangan ko hin rosaryo it iya kamot” as verbalized by the wife

PHYSICAL EXAMINATION

GENERAL APPEARANCE Client has decreased level of consciousness, lethargic, drowsy, easily
and NEUROLOGIC aroused with voices, but unable to orient himself the time and place. He was
EXAMINATION not able to communicate but incomprehensible sounds were noted with right
side body weakness noted. He is lying in bed in supine position, with neck
stiffening. He is wearing oversized white t-shirt and black shorts. Clean and
well-groomed. Client showed easy fatigability.
VITAL SIGNS BP: 180/90 mmHg
HR: 127 bpm
RR: 35 cpm
Temperature: 38.7ºC
O2Sat: 90%
Skin, Hair, & Nails

SKIN:
• Dark brown, warm to touch, turgor intact with immediate recoil of
skin over the clavicle and flushed skin noted. No abscess noted on
HAIR: the abdomen, back and thighs. No cyanosis noted.

NAILS: • Black, short, and straight. No scalp lesions or flaking noted. Hair is
smooth and firm evenly distributed. Scalp is clean and dry. Sparse
dandruff may be visible. Hair is coarser and drier.

• Short and clean. Capillary refill of < 3 seconds. No signs of clubbing

of nails
HEAD: • Normocephalic, no lesions, or bumps. The head is normally hard
and smooth without lesions. The temporal artery is elastic and not
tender. There is no swelling, tenderness or crepitation with
NECK: movement.

• Neck is symmetric with no bulging masses. Nuchal stiffness and

dysphagia noted.
EYES: • Eyebrows sparse with equal distribution. Bulbar conjunctiva clear
 and moist. Pale palpebral conjunctiva noted. Sclera is white,
without increased vascularity or lesions noted.

• Lacrimal apparatus non-edematous

• Bilateral auricles without deformity, lumps or lesions

EARS:
MOUTH: • Lips are pale and snooth, no lesions or ulcerations. Buccal mucosa
is moist. Gums pinkish and moist without inflammation, bleeding
or discoloration. Hard and soft palate have no lesions. Tongue is
midline without lesions or masses. Right side of the lip drooped
NOSE: and excessive drooling was noted.

• Nares patent. Nasal septum in midline without deviation. No

discharges noted.
THORAX AND LUNGS • No use of accessory muscles when breathing. No wheezing, rales,
crackles noted upon auscultation. No nasal flaring. Elevated
respiratory rate of 35 cpm.
HEART AND NECK • No carotid bruit or jugular vein distention noted. No murmurs,
VESSELS gallops, or clicks heard upon auscultation. Elevated blood pressure
of 180/90 and elevated heart rate of 127 bpm.
ABDOMEN • Abdomen round and symmetric, without masses, lesions, pulsations,
or peristaltic waves. Abdomen free of hair, bruising or increased
vasculature. Umbilicus in midline, without herniation, swelling or
discoloration. Bowel sounds low pitched and gurgling. Abdomen
tympanic. No tenderness noted with light or deep palpation.

MUSCULOSKELETAL

UPPER EXTREMITIES: • Radial and brachial pulses 2+ and equal bilaterally. Equal in size and
symmetric. Skin is dark brown, warm and dry to touch, without
edema, bruising or lesions. Weakness on right hand noted. Nuchal
stiffening noted.

LOWER EXTREMITIES:
• Symmetric in size and shape. Skin is intact, dark brown, warm and
dry to touch, without edema. Dorsalis pedis and posterior tibial
pulses 1 + and equal bilaterally. Weakness on right leg noted.

• Upper and lower extremities symmetric, without lesions, nodules,

deformities or swelling. Right sided body weakness noted and
nuchal stiffening.
GENTALIA • Not assessed
ANUS AND RECTUM • Not assessed
REVIEW OF SYSTEMS

INTEGUMENTARY Skin is warm to touch and flushed. With normal skin turgor. Full hair
SYSTEM distribution on scalp, and normal hair distribution on arms and legs. Nails
neatly trimmed. Capillary refill <3 seconds. No lesions noted.
HEAD, EYES, EARS, Head is normocephalic and without lesions or bumps. Hair is straight without
NOSE, THROAT patches or ball spots and scalp is clean. Noted right sided facial drooping.
Eyes are distantly placed and equal in size and shape with thick black
eyelashes. No redness, discharge or crusting was noted on lid margins. Sclera
is white without lesions or redness.
Ears are equally bilaterally. Auricles are aligned with the corner of each eye.
Skin is smooth, no lumps, lesions or nodules. No discharge. Nontender on
palpation.
Lips is pale, smooth, and moist without lesions and excessive drooling noted.
Nose is normal size but smooth, symmetric, and midline. Each nares is patent.
Nasal septum is slightly deviated to the left but does not obstruct airflow. No
purulent drainage was noted. Frontal and maxillary sinuses are non-tender
upon palpitation.
Neck symmetric with centered head position and bulging masses. Nuchal
stiffness and dysphagia noted. Lymph nodes are non-palpable.
MUSCULOSKELETAL Decrease range of motion (ROM) of joints noted on the right side of the
body. No swelling of metacarpals, wrists, knees, and ankles was observed.
Nuchal stiffness noted, No claudication, cramping, skin lesions, or edema of
legs and feet.
RESPIRATORY SYSTEM No chest pain noted. Respiratory rate of 35, without use of accessory
muscles, symmetrical chest wall movement, and clear breath sounds in all lung
fields. Oxygen saturation of 90% in room air.
CARDIOVASCULAR Elevated blood pressure of 180/90 and elevated heart rate of 127 bpm.
SYSTEM Chest is symmetrical expansion with respiration, no scars. No cardiac heaves
or lifts. No thrills palpated. PMI is noted at the fifth intercostal space and
midclavicular line.
HEMATOLOGIC Does not easily bruise. No bleeding gums and blood clots. Hemoglobin,
SYSTEM hematocrit and RBC results are in normal level. Results as follow: Hg = 144
g/L; Hct = 0.42 L/L and RBC = 5.00 x10 ^12/L
GASTROINTESTINAL Constipation noted, no defecation for 5 days. The abdomen is rounded,
SYSTEM symmetrical. The umbilicus is midline and no odor or discharge noted.
Abdomen is soft, non-distended, non-tender with positive bowel sounds to all
four quadrants and no guarding noted during the assessment.
GENITOURINARY Able to urinate, change of diaper 3 times a day.
SYSTEM
NERVOUS SYSTEM Client has decreased level of consciousness and lethargic, drowsy, easily
aroused with voices, but unable to orient himself the time and place. He is
not able to communicate. Right side body weakness noted. He is lying in
 bed in supine position, with neck stiffening.

Glasgow Coma Scale

August 30, 10pm
GCS 10 - E3 (Eye opening to speech)
V2 (Verbal response - incomprehensible sounds)
M5 (motor response - moves to localised pain)

August 31, 2am

GCS 7 - E1 (No response)
V1 (No response)
M5 (motor response - moves to localised pain)

September 1, 7pm
GCS 8 - E2 (Eye opening to pain)
V1 (No response)
M5 (motor response - moves to localised pain)
September 2, 8 am
GCS 8- E2 (Eye opening to pain)
V1 (No response)
M5 (motor response - moves to localised pain)
September 3, 10 am
GCS 9- E2 (Eye opening to pain)
V2 (Verbal response - incomprehensible sounds)
M5 (motor response - moves to localised pain)
September 4, 8 am
GCS 11 - E3 (Eye opening to speech)
V2 (Verbal response - incomprehensible sounds)
M6 (motor response - moves to localised pain)
LYMPHATIC SYSTEM No edema was noted.

STROKE SCALE
INSTRUCTIONS SCALE DEFINITION SCORE
1a. Level of Consciousness: The investigator must choose a response if a 0 = Alert; keenly responsive.
full evaluation is prevented by such obstacles as an endotracheal tube, 1 = Not alert; but arousable by minor
language barrier, orotracheal trauma/bandages. A 3 is scored only if the stimulation to obey, answer, or respond.
patient makes no movement (other than reflexive posturing) in response to 2 = Not alert; requires repeated stimulation 1
noxious stimulation. to attend, or is obtunded and requires
strong or painful stimulation to make
movements (not stereotyped).
3 = Responds only with reflex motor or
autonomic effects or totally unresponsive,
flaccid, and areflexic
1b. LOC Questions: The patient is asked the month and his/her age. The 0 = Answers both questions correctly.
answer must be correct - there is no partial credit for being close. Aphasic 1 = Answers one question correctly.
and stuporous patients who do not comprehend the questions will score 2. 2 = Answers neither question correctly
Patients unable to speak because of endotracheal intubation, orotracheal
trauma, severe dysarthria from any cause, language barrier, or any other 1
problem not secondary to aphasia are given a 1. It is important that only
the initial answer be graded and that the examiner not "help" the patient
with verbal or non-verbal cues.
1c. LOC Commands: The patient is asked to open and close the eyes and 0 = Performs both tasks correctly.
then to grip and release the non-paretic hand. Substitute another one step 1 = Performs one task correctly.
command if the hands cannot be used. Credit is given if an unequivocal 2 = Performs neither task correctly. 1
attempt is made but not completed due to weakness. If the patient does not
respond to command, the task should be demonstrated to him or her
(pantomime), and the result scored (i.e., follows none, one or two
commands). Patients with trauma, amputation, or other physical
impediments should be given suitable one-step commands. Only the first
attempt is scored.
2. Best Gaze: Only horizontal eye movements will be tested. Voluntary or 0 = Normal.
reflexive (oculocephalic) eye movements will be scored, but caloric testing 1 = Partial gaze palsy; gaze is abnormal in
is not done. If the patient has a conjugate deviation of the eyes that can be one or both eyes, but forced deviation or
overcome by voluntary or reflexive activity, the score will be 1. If a patient total gaze paresis is not present.
has an isolated peripheral nerve paresis (CN III, IV or VI), score a 1. Gaze 2 = Forced deviation, or total gaze paresis 0
is testable in all aphasic patients. Patients with ocular trauma, bandages, not overcome by the oculocephalic
pre-existing blindness, or other disorder of visual acuity or fields should be maneuver.
tested with reflexive movements, and a choice made by the investigator.
Establishing eye contact and then moving about the patient from side to
side will occasionally clarify the presence of a partial gaze palsy.
3. Visual: Visual fields (upper and lower quadrants) are tested by 0 = No visual loss.
confrontation, using finger counting or visual threat, as appropriate. 1 = Partial hemianopia.
Patients may be encouraged, but if they look at the side of the moving 2 = Complete hemianopia.
fingers appropriately, this can be scored as normal. If there is unilateral 3 = Bilateral hemianopia (blind including 0
blindness or enucleation, visual fields in the remaining eye are scored. cortical blindness).
Score 1 only if a clear-cut asymmetry, including quadrantanopia, is found.
If patient is blind from any cause, score 3. Double simultaneous
stimulation is performed at this point. If there is extinction, patient receives
a 1, and the results are used to respond to item 11.
4. Facial Palsy: Ask – or use pantomime to encourage – the patient to 0 = Normal symmetrical movements.
show teeth or raise eyebrows and close eyes. Score symmetry of grimace 1 = Minor paralysis (flattened nasolabial
in response to noxious stimuli in the poorly responsive or non- fold, asymmetry on smiling).
comprehending patient. If facial trauma/bandages, orotracheal tube, tape or 2 = Partial paralysis (total or near-total 2
other physical barriers obscure the face, these should be removed to the paralysis of lower face).
extent possible 3 = Complete paralysis of one or both sides
(absence of facial movement in the upper
and lower face).
Motor Arm: The limb is placed in the appropriate position: extend the arms 0 = No drift; limb holds 90 (or 45) degrees
(palms down) 90 degrees (if sitting) or 45 degrees (if supine). Drift is for full 10 seconds.
scored if the arm falls before 10 seconds. The aphasic patient is 1 = Drift; limb holds 90 (or 45) degrees, LEFT
encouraged using urgency in the voice and pantomime, but not noxious but drifts down before full 10 seconds; ARM=0
stimulation. Each limb is tested in turn, beginning with the non-paretic does not hit bed or other support.
arm. Only in the case of amputation or joint fusion at the shoulder, the 2 = Some effort against gravity; limb
examiner should record the score as untestable (UN), and clearly write the cannot get to or maintain (if cued) 90 (or RIGHT
explanation for this choice. 45) degrees, drifts down to bed, but has ARM=
some effort against gravity. 4
3 = No effort against gravity; limb falls.
4 = No movement.
UN = Amputation or joint fusion, explain:
6. Motor Leg: The limb is placed in the appropriate position: hold the leg 0 = No drift; limb holds 90 (or 45) degrees LEFT
at 30 degrees (always tested supine). Drift is scored if the leg falls before 5 for full 10 seconds. LEG=0
seconds. The aphasic patient is encouraged using urgency in the voice and 1 = Drift; limb holds 90 (or 45) degrees,
pantomime, but not noxious stimulation. Each limb is tested in turn, but drifts down before full 10 seconds;
beginning with the non-paretic leg. Only in the case of amputation or joint does not hit bed or other support. RIGHT
fusion at the hip, the examiner should record the score as untestable (UN), 2 = Some effort against gravity; limb LEG= 4
and clearly write the explanation for this choice. cannot get to or maintain (if cued) 90 (or
45) degrees, drifts down to bed, but has
some effort against gravity.
3 = No effort against gravity; limb falls.
4 = No movement.
UN = Amputation or joint fusion, explain
7. Limb Ataxia: This item is aimed at finding evidence of a unilateral 0 = Absent.
cerebellar lesion. Test with eyes open. In case of visual defect, ensure 1 = Present in one limb.
testing is done in intact visual field. The finger-nose-finger and heel-shin 2 = Present in two limbs.
tests are performed on both sides, and ataxia is scored only if present out UN = Amputation or joint fusion, explain 1
of proportion to weakness. Ataxia is absent in the patient who cannot
understand or is paralyzed. Only in the case of amputation or joint fusion,
the examiner should record the score as untestable (UN), and clearly write
the explanation for this choice. In case of blindness, test by having the
patient touch nose from extended arm position.
8. Sensory: Sensation or grimace to pinprick when tested, or withdrawal 0= Normal; no sensory loss.
from noxious stimulus in the obtunded or aphasic patient. Only sensory 1 = Mild-to-moderate sensory loss; patient
loss attributed to stroke is scored as abnormal and the examiner should test feels pinprick is less sharp or is dull on the
as many body areas (arms [not hands], legs, trunk, face) as needed to affected side; or there is a loss of
accurately check for hemisensory loss. A score of 2, “severe or total superficial pain with pinprick, but patient is 1
sensory loss,” should only be given when a severe or total loss of sensation aware of being touched.
can be clearly demonstrated. Stuporous and aphasic patients will, 2 = Severe to total sensory loss; patient is
therefore, probably score 1 or 0. The patient with brainstem stroke who has not aware of being touched in the face,
bilateral loss of sensation is scored 2. If the patient does not respond and is arm, and leg.
quadriplegic, score 2. Patients in a coma (item 1a=3) are automatically
given a 2 on this item.
9. Best Language: A great deal of information about comprehension will 0 = No aphasia; normal.
be obtained during the preceding sections of the examination. For this 1 = Mild-to-moderate aphasia; some
scale item, the patient is asked to describe what is happening in the obvious loss of fluency or facility of
attached picture, to name the items on the attached naming sheet and to comprehension, without significant
read from the attached list of sentences. Comprehension is judged from limitation on ideas expressed or form of
responses here, as well as to all of the commands in the preceding general expression. Reduction of speech and/or
neurological exam. If visual loss interferes with the tests, ask the patient to comprehension, however, makes
identify objects placed in the hand, repeat, and produce speech. The conversation about provided materials
intubated patient should be asked to write. The patient in a coma (item difficult or impossible. For example, in
1a=3) will automatically score 3 on this item. The examiner must choose a conversation about provided materials, 2
score for the patient with stupor or limited cooperation, but a score of 3 examiner can identify picture or naming
should be used only if the patient is mute and follows no one-step card content from patient’s response.
commands. 2 = Severe aphasia; all communication is
through fragmentary expression; great need
for inference, questioning, and guessing by
the listener. Range of information that can
be exchanged is limited; listener carries
burden of communication. Examiner
cannot identify materials provided from
patient response.
3 = Mute, global aphasia; no usable speech
or auditory comprehension.
10. Dysarthria: If patient is thought to be normal, an adequate sample of 0 = Normal.
speech must be obtained by asking patient to read or repeat words from the 1 = Mild-to-moderate dysarthria; patient
attached list. If the patient has severe aphasia, the clarity of articulation of slurs at least some words and, at worst, can
spontaneous speech can be rated. Only if the patient is intubated or has be understood with some difficulty.
other physical barriers to producing speech, the examiner should record the 2 = Severe dysarthria; patient's speech is so 2
score as untestable (UN), and clearly write an explanation for this choice. slurred as to be unintelligible in the
Do not tell the patient why he or she is being tested. absence of or out of proportion to any
dysphasia, or is mute/anarthric.
UN = Intubated or other physical barrier,
explain:
11. Extinction and Inattention (formerly Neglect): Sufficient information 0 = No abnormality.
to identify neglect may be obtained during the prior testing. If the patient 1 = Visual, tactile, auditory, spatial, or
has a severe visual loss preventing visual double simultaneous stimulation, personal inattention or extinction to
and the cutaneous stimuli are normal, the score is normal. If the patient has bilateral simultaneous stimulation in one of
aphasia but does appear to attend to both sides, the score is normal. The the sensory modalities. 0
presence of visual spatial neglect or anosagnosia may also be taken as 2 = Profound hemi-inattention or extinction
evidence of abnormality. Since the abnormality is scored only if present, to more than one modality; does not
the item is never untestable. recognize own hand or orients to only one
side of space.
TOTAL 19
severe
 LABORATORY & DIAGNOSTIC EXAMINATIONS
HEMATOLOGY RESULT FORM - COMPLETE BLOOD COUNT RESULT

RESULT NORMAL
TEST CLINICAL SIGNIFICANCE
(09/01/22) VALUES
Hgb 144 140-170 NORMAL
g/dL
Hct 0.42 0.42 – 0.52 NORMAL
L/L
RBC 5.00 4.7-6.1 NORMAL
WBC H 12.83 4.8-10.8 The increase of WBC level is a kind of stress reaction when acute
cerebrovascular disease occurs, it often occurs at the early clinical
stage of acute cerebrovascular disease.
Neutrophils H 0.92 0.43-0.65 The inflammatory response is a key mechanism in Cerebrovascular
disease (CVD). Neutrophils secrete inflammatory mediators that
can cause vascular wall degeneration, leading to cerebrovascular
hemorrhage.
Lymphocytes L 0.05 0.20-0.45 Lymphocytes regulate the inflammatory response and thus have an
antiatherosclerosis role. A combined increase in neutrophils and a
decrease in lymphocytes during inflammation in CVD manifests
an elevated neutrophil to lymphocyte ratio, thereby indicating the
severity of neural damage.
Monocytes L 0.03 0.05-0.12 Under both normal and diseased conditions, the brain will recruit
monocytes to the brain blood vessels and these monocytes further
infiltrate into the brain parenchyma. The monocyte can help with
tissue remodeling and regeneration in diseased conditions.
Therefore, low monocyte, there is possibility of brain blood vessels
damage leading to brain hemorrhage.
Eosinophil L 0.00 0.01-0.03 Inflammation may determine the prognosis of intracerebral
hemorrhage; recent studies have increasingly demonstrated
eosinopenia as a prognostic factor.
Basophil 0.00 0-0.01 NORMAL
MCV 85 80-94 NORMAL
MCH 29 27-31 NORMAL
MCHC 340 320-360 NORMAL
Platelet 218 150-400 NORMAL
Blood Type “O”
RH Positive
CHEMISTRY RESULT FORM

RESULT NORMAL
TEST CLINICAL SIGNIFICANCE
(09/01/22) VALUES
FBS H 9.06 4.1-6.6 Higher baseline blood glucose levels in the absence of diabetes
can be a result of stress response of the body. Too much stress can
release hormones such as cortisol and adrenaline which are the
primary hormones that can increase the blood sugar.
HDL Ratio H 4.75 2.94-4.62 HDL was high in hemorrhagic stroke. HDL removes LDL
cholesterol from the bloodstream and the artery walls. As levels of
LDL cholesterol is high, HDL ratio is also high.
Total H 8.31 3.6-5.7 Cholesterol changes, especially larger changes, lead to an increase
Cholesterol in CVD, which demonstrates that cholesterol variability may
 increase CVD.
Triglycerides 1.06 0.45-2.26 NORMAL
HDL 1.75 0.78-1.94 NORMAL
Cholesterol
LDL H 6.35 1.66-3.89 Too much LDL can build up in the artery walls and form plaque
Cholesterol that narrows arteries and restricts blood flow. This situation is
similar with CVA. When there is high LDL, cerebral artery walls
narrows and restriction of blood flow will occur, this may also
cause CVD bleed later on. Low levels of LDL cholesterol show
limited predictive power for cerebrovascular events
Hemoglobin 6.0 3.90-6.5 NORMAL
A1C
VLDL 0.21 0-1.03 NORMAL

CHEMISTRY RESULT FORM

RESULT NORMAL
TEST CLINICAL SIGNIFICANCE
(09/01/22) VALUES
Creatinine 113.68 60-115 NORMAL
Sodium 136.5 135-148 NORMAL
Potassium L 3.17 3.5-5.3 Severely ill patients like those with CVD release more
catecholamines, leading to lower serum potassium level.
Chloride L 94.4 98-107 Because the blood concentration of positively charged electrolytes
must equal that of negatively charged electrolytes, conditions that
cause the loss of sodium or potassium often result in low blood
chloride level

HEMATOLOGY RESULT FORM - COAGULATION RESULT

EXAMINATION RESULT (09/01/22) REFERENCE RANGE CLINICAL SIGNIFICANCE

PT CONTROL 10.8 NORMAL
PT 10.40 9.4 - 12.5 NORMAL
% Activity 111.00 NORMAL
INR 0.95 NORMAL
APPT Control 29.1 NORMAL
APPT 26.90 25.1-36.5 NORMAL

CT SCAN INITIAL RESULTS

AUGUST 31 2022
Initial CT Scan 70 cc blood (L) MCA
 COURSE IN THE WARD

DATE TREATMEN MEDICATIONS IVF DIET DIAGNOSTIC SPECIAL SIGNIFICANCE

T S ENDORSEMENT

DAY 1 ● Give ● Add: Start ● Admit to ED Diagnostics:

nicardipine 2 PNSS cranial CT ● If SBP is still >
8/30/22 - 10:00 pm mg IV now IL x NPO scan - done 150, refer ● CT scan uses a series
then repeat BP 8 hrs ● For FBC and of X-rays to create a
thereafter NGT insertion detailed image of your
● Nicardipine brain. A CT scan can
drip: 10 mg + show bleeding in the
90 cc PNSS to brain, an ischemic
start at 5 cc/hr, stroke, a tumor or
uptitrate by 2 other conditions.
cc/hr to Medication:
maintain SBP < ● Nicardipine - is
150 mmHg indicated for the
treatment of
hypertension,
including
hypertensive urgency
and hypertensive
emergency.

IVF: For most patients

with acute stroke and
volume depletion, isotonic
saline without dextrose is
the agent of choice for
intravascular fluid
repletion and maintenance
fluid therapy.
8/30/22 - 10:14 pm
DIET: The typical reason
Initial CT scan ● Refer to Neuro
for NPO instructions is the
GS for further
prevention of aspiration,
70 cc blood (L) evaluation with weak swallowing
MCA musculature.
Refused FBC and
NGT insertion.

GCS 10
BP: 230/110
HR: 98
RR: 23
TEMP: 36
O2: 98%

DAY 2 ● Mannitol 150 cc PNSS NPO ● CBC ● May transfer Diagnostics:

IV q4h IL x ● BT to SW1
8/31/22 - 2:00 AM ● Dexamethasone 8 hrs ● NaKCl ● Secure consent ● Complete blood
● ● Insert NGT count - helps
● E1V1M5 8mg IV then Creatinine
diagnose infection,
● GCS 7 4mg IV q6h ● PT/PTT ● Start OF 1400
● Omeprazole 40 ● anemia, clotting
● (+) aphasia FBS kcal in 6 meals
problems, or other
● CVD bleed, mg IV OD ● Lipid ● Refer to IM
● Atorvastatin 40 profile Cardio for blood problems.
left
capsuloganglio mg per NGT ● HbA1c evaluation and ● Serum electrolytes -
OD HS ● 12 L ECG comanagement is a blood test that
nic (70 cc) measures levels of the
● Lactulose 30 cc ● Insert FBC
per NGT ● Monitor BP q body's main
Refused FBC and electrolytes. The
NGT insertion ● Nicardipine drip hour strictly
as ordered ● Refer disorders of sodium
uptitrate by 2 (Na) and potassium
VS: 8 AM (K) balance are
cc/hr until SBP
< 160 identified as the most
BP: 190/120 common electrolyte
HR: 85 abnormalities in
RR:24 patients with acute
TEMP: 36.4 stroke. Patients with
O2SAT: 99%
 hemorrhagic stroke
present with
symptoms like
headache and
vomiting, which in
turn is a potential
cause of electrolyte
imbalance.
● Blood clotting test -
these tests measure
how quickly your
blood clots. It is also
called a coagulation
panel. If a patient’s
blood clots too
quickly, stroke may
have been caused by a
clot (ischemic stroke).
If blood clots too
slowly, stroke may
have been caused by
bleeding
(hemorrhagic stroke).
● HbA1c- is a simple
blood test that
measures your
average blood sugar
levels over the past 3
months. A higher
HbA1c indicated a
significantly
increased risk for
ischaemic stroke.
● Lipid profile - is a
blood test that can
measure the amount
of cholesterol and
triglycerides in your
 blood. This test
examines whether
high blood cholesterol
might have led to
stroke
● Electrocardiogram
(ECG, EKG) which
checks the hearts'
electrical activity, can
help determine
whether heart
problems caused the
stroke.
Medication:
● Mannitol - reduce
pressure around the
brain (high ICP).
● Dexamethasone -
acute exacerbations of
cerebral edema
● Omeprazole - used to
treat dyspepsia, a
condition that causes
sour stomach,
belching, heart burn,
or indigestion.
● Atorvastatin -
primary prevention of
cardiovascular disease
in high- risk pts.
Reduces risk of stroke
in pts with or without
evidence of heart
disease with multiple
risk factors other than
diabetes.
● Lactulose - treatment
 of chronic
constipation.
● Nicardipine - is
indicated for the
treatment of
hypertension,
including
hypertensive urgency
and hypertensive
emergency.

IVF: For most patients

with acute stroke and
volume depletion, isotonic
saline without dextrose is
the agent of choice for
intravascular fluid
repletion and maintenance
fluid therapy.
DIET: The typical reason
for NPO instructions is the
prevention of aspiration,
with weak swallowing
musculature.

DAY 3 Continue Conti NPO ● For RT ● ff up Diagnostics

medications nue PCR Test borderline
9/1/22 - 7:00 PM IVF labs ● RT-PCR test, also
● Pt family called a molecular test,
GCS 8 E2V1M5 this COVID-19 test
appraised on
Isocoric pupil pt current detects genetic
status and material of the virus
Refused standby using a lab technique
‘E’ intubation with condition
● For ‘E’ called reverse
signed consent. transcription
Intubation
● Undecided polymerase chain
reaction (RT-PCR).
VS: 8 AM for ‘E’ This is essentially
intubation ordered during the
BP:220/100 ● Risk and patient's admission.
HR: 97 consequences
explained and
RR:25 understood Medication:

TEMP: 37.2 by SO ● Nicardipine - is

● Pls secure indicated for the
O2: 97% signed waiver treatment of
● Monitor VS hypertension,
● Refer to IM including
Cardio for hypertensive urgency
evaluation and hypertensive
and co-mgt emergency.
of
Hypertension
● Continue ● ‘E’ Intubation -
present mgt Patients with stroke
● Pls regulate require endotracheal
nicardipine intubation because of
drip a decreased level of
● Monitor BP q consciousness, airway
hr C/O clerk compromise, hypoxia,
● Refer or apnea, or for
initiation of
therapeutic
hyperventilation.

DAY 4 ● Maintain Conti FOR NGT ● Please Medications:

nicardipine drip, nue INSERTION monitor BP
9/2/22 - 7:30 AM uptitrate by 5 cc IVF q 1 hour for
● On q 30 mins until now - ● Nicardipine. I.V.
Nicardipine able to achieve record pls is indicated for the
drip @ SBP <150 treatment of
64/cc/hr mmHg hypertension,
● Referred ● Start Clonidine including
due to 75 mg 1 tab, 1 hypertensive
persistent tab TID/NGT urgency and
 elevated BP ● Start hypertensive
going day 3 Amlodipine 5 emergency.
post ictus mg 1 tab, 1 tab ● Clonidine is in a
● K = 3.17 OD class of
● Known ● Start KCl tab 2 medications called
HPN since tabs TID x 5 centrally acting
2018 with doses/ NGT alpha-agonist
poor ● Continue hypotensive
compliance Atorvastatin 40 agents. Clonidine
to meds mg 1 tab OD treats high blood
● BP: 180/90 HS/ NGT pressure by
(L) decreasing your
● MAP 120 heart rate and
● Refused relaxing the blood
NGT vessels so that
insertion blood can flow
with signed ● Please uptitrate more easily
consent. Nicardipine drip through the body.
VS: 8 AM by 5 cc/hr to ● Amlodipine is in a
maintain SBP class of
BP: 180/90 mmHg <150 mmHg medications called
HR: 127 bpm ● Cont. Clonidine calcium channel
● Cont. blockers. It lowers
RR: 35 cpm Amlodipine blood pressure by
● Cont. relaxing the blood
Temperature: Atorvastatin
38.7ºC vessels so the heart
does not have to
O2Sat: 90% pump as hard. It
controls chest pain
by increasing the
supply of blood to
the heart.
● Potassium
chloride is used to
prevent or treat
low blood levels of
potassium
(hypokalemia).
 ● Head ● Atorvastatin -
always at primary prevention
midline of cardiovascular
9/2/22 - 5:30 PM ● May start ● Head of disease in high-
OF divided bed at 30- risk pts. Reduces
into 6 equal 45 degrees risk of stroke in pts
feeding with ● Turn to with or without
50-100 ml sides q 2 evidence of heart
water hrs disease with
flushes pre ● Refer multiple risk
and post factors other than
feeding diabetes.

Diet: A range of enteral

feeding tubes and feeding
methods may be used to
support stroke patients
who are unable to meet
their nutritional
requirements through oral
intake alone, thus OF was
ordered.

● Pt. family
appraised
on pt.
Current
9/2/22 - 9 PM condition
● Still
undecided
for
operation
● Monitor VS
● Monitor BP
q hr
● Refer
DRUG STUDY

NAME OF MECHANISM INDICATION CONTRAINDICATION SIDE NURSING

DRUG OF ACTION & CAUTION EFFECTS/ADVERSE RESPONSIBILITIES
EFFECTS

BEFORE:
Generic Name: Inhibits HMG- Primary Contraindications: Side Effects
CoA reductase, prevention of Active hepatic disease, o Consider the different
Atorvastatin the enzyme that cardiovascular unexplained elevated Common: Atorvastatin is rights to drug
catalyzes the disease in hepatic function test generally well tolerated. Side administration:
Trade Name: early step in high-risk pts. results. effects are usually mild and o Right Assessment
cholesterol Reduces risk of transient. o Right Patient
Lipitor synthesis. stroke in pts Caution: o Right Drug
with or without Frequent (16%): Headache. o Right Dose
Therapeutic Therapeutic evidence of Anticoagulant therapy; o Assess baseline lab results:
Class: Effect: heart disease history of hepatic disease; Occasional (5%–2%): cholesterol, triglycerides,
Decreases LDL with multiple substantial alcohol Myalgia, rash, pruritus, hepatic function tests.
Antilipimecs and VLDL, risk factors consumption; major allergy. o Obtain dietary history
plasma other than surgery; severe acute o Assess for gurgling sound
Pharmacologic triglyceride diabetes. infection; trauma; Rare (less than 2%–1%): for NGT patency.
Class: levels; increases hypotension; severe Flatulence, dyspepsia, o Crush tablets separately
HDL metabolic, endocrine, depression. from other drugs.
HMG CoA concentration. electrolyte disorders; o Dilute using 30 ml of warm
reductase uncontrolled seizures. Adverse Effects/ Toxic water.
inhibitors Reactions
DURING:
Patient’s Dose: Potential for cataracts, o Consider the different rights
Drug to Drug photosensitivity, myalgia, to drug administration:
40 mg per NGT Interactions: rhabdomyolysis. o Right Approach
OD HS o Right Route
Amiodarone: May increase o Right Dose
risk of severe myopathy of o Right Time
rhabdomyolysis. Avoid use o Right Principle of Care
together or decrease o Flush NGT tube with warm
atorvastatin dose. water before and after
giving the medicine.
Antacids, o Monitor for headache.
Cholecystyramine, o Monitor cholesterol,
Colestipol: may decrease triglyceride lab values for
Atorvastatin level. therapeutic response.
o Monitor hepatic function
Boceprevir: May increase tests, CPK.
Atorvastatin level and risk
of myopathy. AFTER:
o Periodic lab tests are
Cyclosporine: May essential part of therapy.
increase statin level and o Report dark urine, muscle
risk of myopathy. fatigue, bone pain.
o Document administration
after giving the ordered
medication. Chart the
time, route, and any other
specific information as
necessary.

Treatment of o Hypersensitivity GI: Flatulence, borborygmi, BEFORE

Generic Name: chronic belching, abdominal cramps, ADMINISTRATION:
Produces osmotic o Patients on low- pain, and distention (initial
constipation o Consider the different rights
Lactulose effect in colon. galactose diets.
Resulting dose); diarrhea (excessive to drug administration:
distention dose); nausea, vomiting, o Right Assessment
Trade Name: colon accumulation of
promotes Use Cautiously in patients o Right Patient
peristalsis. with: hydrogen gas; o Right Drug
Cephulac, hypernatremia.
Decrease blood o Diabetes mellitus o Right Dose
Chronulac ammonia build-up o Determine history of
that causes hepatic o Excessive or hypersensitivity reactions.
Pharmacologic encephalopathy, prolonged use
Class: Endo: hyperglycemia o Assess for the mentioned
probably as result (may lead to cautions and
(diabetic patients). pain,
of bacterial dependence) contraindications to prevent
Hyperosmotic muscle cramps.
degradation, which any untoward
lowers pH of colon complications.
Laxative contents. o Obtain baseline vital signs
Drug to Drug Interactions: to determine any potential
Patient’s Dose: o LAXATIVES may adverse effects.
Therapeutic incorrectly suggest o Assess for abdominal
30 cc per NGT effect: therapeutic action distention.
of lactulose. o Assess for gurgling sound
for NGT patency.
Relieves o Should not be used DURING:
constipation, with other laxatives o Consider the different rights
decreases blood in the treatment of to drug administration:
ammonia hepatic o Right Approach
concentration. encephalopathy o Right Route
(leads to inability to o Right Dose
determine optimal o Right Time
dose of lactulose). o Right Principle of Care
o Anti-infectives may o Instruct to take lactulose as
↓ effectiveness in directed.
treatment of hepatic o Given without regards to
encephalopathy. meals, may be given before
or after meals
AFTER:
o Lab Test Considerations:
Monitor serum electrolytes
periodically when used
chronically. May cause
diarrhea with resulting
hypokalemia and
hypernatremia.
o Evaluate patient for
abdominal distention,
presence of bowel sounds,
and normal pattern of bowel
function.
o Document administration
after giving the ordered
medication. Chart the time,
route, and any other specific
information as necessary.
 Contraindications: Adverse effects: Before:

Generic Name: Inhibits calcium None known. o excessive peripheral 1. Consider the different rights
movement across Hypertension vasodilation to drug administration:
Amlodipine cardiac and o Right Assessment
o marked hypotension o Right Patient
vascular smooth CAUTIONS:
Therapeutic muscle cell o with reflex o Right Drug
Class: membranes. Hepatic impairment, aortic tachycardia. o Right Dose
stenosis, 2. Assess patient for any
Antihypertensive possible contraindications and
hypertrophic any known allergy.
Decreases total cardiomyopathy. Side effects:
Pharmacologic 3. Assess B/P.
peripheral vascular
Class: o Peripheral edema 4. Assess for peripheral
resistance and B/P
edema behind medial malleolus
by vasodilation. Drug to Drug Interactions: o Headache
Calcium (sacral area in bedridden pts).
Channel o Flushing 5. Assess skin for
Conivaptan: May increase
Blockers flushing. Question for headache,
amlodipine plasma
Occasional (5%–1%): asthenia (loss of strength,
concentration. Monitor
Patient’s Dose: energy)
patient for hypotension and o Dizziness 6. Assess for gurgling
5 mg/tab 1 tab OD edema. sound for NGT patency
o Palpitations
per NGT 7. Crush tablets separately
Cyclosporine: may increase
o Nausea from other drugs
levels of both drugs. Monitor
levels and patient. 8. Dilute using 30 ml of
o unusual fatigue or
warm water.
weakness (asthenia)
Sildenafil: May increase risk
of hypotension. Monitor BP Rare (less than 1%): During:
closely. Consider the different rights to
o Chest pain
drug administration:
o Bradycardia o Right Approach
o Right Route
o orthostatic o Right Dose
hypotension o Right Time
o Right Principle of Care
Flush NGT tube with warm
water before and after giving
the medicine.
 After:
1. Consider the different rights
to drug administration:
o Right Education
o Right Evaluation
o Right Documentation
2. Do not abruptly
discontinue
medication.
3. Compliance
with therapy
regimen is
essential to
control
hypertension.
4. Avoid tasks
that require
alertness, motor
skills until
response to
drug is
established.
5. Avoid
concomitant
ingestion of
grapefruit juice.

Before:
o Consider the different
Generic Name: Maintains acid- o To o Hypersensitivity to CNS: confusion, unusual rights to drug
base balance, prevent tartrazine or fatigue, restlessness, administration:
Potassium isotonicity, potassium
o alcohol (with some asthenia, flaccid paralysis, o Right Assessment
Chloride depletion
and products) paresthesia, o Right Patient
electrophysiologic o Right Drug
Therapeutic o Acute dehydration absent reflexes o Right Dose
balance
Class: o Assess vital signs and
o Heat cramps CV: ECG changes,
throughout body ECG. Stay alert for
Potassium hypotension,
tissues; crucial to o Hyperkalemia arrhythmias.
Supplement nerve impulse o Hyperkalemic
transmission and familial periodic
Pharmacologic contraction paralysis
Class:
of cardiac, skeletal, o Severe renal
impairment
Potassium salts and
smooth muscle. o Severe hemolytic
Patient’s Dose:
Also essential for reactions
KCl tab normal
o Severe tissue trauma
2 tabs TID x 5 renal function and
o Untreated Addison’s
doses/NGT carbohydrate
disease
metabolism. o Esophageal
compression caused
by enlarged left
atrium (with wax
matrix forms)
o Concurrent use of
potassium sparing
diuretics,
angiotensin-enzyme
converting (ACE)
inhibitors, or salt
Use cautiously in:
o cardiac disease, renal
impairment,
diabetes mellitus,
hypomagnesemia
Drug to Drug Interactions:
ACE Inhibitors: May cause
hyperkalemia. Use together
with extreme caution.
arrhythmias, heart block, o As appropriate, review
cardiac all other significant and
life-threatening adverse
arrest reactions and
interactions, especially
GI: nausea, vomiting,
those related to the
diarrhea,
drugs, tests, foods, and
abdominal discomfort, herbs mentioned.
flatulence o Assess for gurgling
sound for NGT
Metabolic: hyperkalemia patency.
Musculoskeletal: weakness o Crush tablets
separately from other
and heaviness
drugs.
of legs o Dilute using 30 ml of
warm water.
Respiratory: respiratory
paralysis During:
o Consider the different
Other: irritation at I.V. site
rights to drug
administration:
o Right Approach
o Right Route
o Right Dose
o Right Time
o Right Principle of
Care
o Flush NGT tube with
warm water before
and after giving the
medicine.
o Monitor neurologic
status. Watch for
neurologic
complications
o Monitor renal function,
fluid intake and output,
and potassium,
creatinine, and blood
urea nitrogen levels.
 Monitor potassium level. o Should be taken with
meals to minimize GI
irritation
o Know that potassium is
contraindicated in
patients with severe
renal impairment and
must be used with
extreme caution (if at
all) in patients with any
degree of renal
impairment, because of
risk of life-threatening
hyperkalemia.
After:
o Consider the different
rights to drug
administration:
o Right Education
o Right Evaluation
o Right Documentation
o Advise patient to report
nausea, vomiting,
confusion, numbness
and tingling, unusual
fatigue or weakness, or
a heavy feeling in legs.
o Inform patient that
although wax matrix
form may appear in
stool, drug has already
been absorbed.
o Advise patient not to
use salt substitutes.

Before
o Consider the different
Clonidine Stimulates alpha- Treatment of Contraindications: Epidural Side effects Frequent: Dry rights to drug
adrenergic hypertension contraindicated in pts with mouth (40%), drowsiness administration:
receptors and alone or in bleeding diathesis or (33%), dizziness (16%),
 inhibits the central combination with infection at the injection site, sedation, constipation (10%). o Right Assessment
vasomotor centers, other those receiving o Right Patient
Therapeutic class: decreasing antihypertensive anticoagulation therapy. Occasional (5%–1%): Tablets, o Right Drug
antihypertensives sympathetic agents Injection: Depression, pedal o Right Dose
outflow to the edema, loss of appetite, o Obtain B/P immediately
heart, kidneys, and decreased sexual function, before each dose is
Cautions: itching eyes, dizziness, nausea,
Pharmacologic peripheral administered, in
class: Centrally vasculature, and Severe coronary vomiting, nervousness. addition to regular
acting alpha lowering peripheral insufficiency; recent MI; Transdermal: Pruritus, redness monitoring (be alert to
agonists vascular resistance, cerebrovascular disease; or darkening of skin. Rare B/P fluctuations).
BP, and HR. chronic renal failure; pre- (less than 1%): Nightmares, During
Dosage: vivid dreams, feeling of
existing bradycardia; sinus o Consider the different
node dysfunction; coldness in distal extremities rights to drug
75mg/tab
conduction disturbances; (esp. the digits). administration:
Therapeutic Effect:
1 tab TID/NGT concurrent use with digoxin, o Right Approach
Reduces peripheral
resistance; diltiazem, metoprolol, o Right Route
decreases B/P, verapamil; depression. Adverse effects/ toxic o Right Dose
heart rate. Produces reactions Overdose produces o Right Time
Drug to Drug Interactions: profound hypotension,
analgesia. o Right Principle of Care
Amitriptyline, amoxapine, irritability, bradycardia, o Monitor B/P, pulse,
clomipramine, desipramine, respiratory depression, mental status.
doxepin, imipramine, hypothermia, miosis (pupillary o Monitor daily pattern of
mirtazapine, nortriptyline, constriction), arrhythmias, bowel activity, stool
protriptyline, trimipramine: apnea. Abrupt withdrawal may consistency.
May cause loss of bp control result in rebound hypertension o If clonidine is to be
with life-threatening associated with nervousness, withdrawn, discontinue
elevations in bp. Avoid using agitation, anxiety, insomnia, concurrent betablocker
together. paresthesia, tremor, flushing, therapy several days
diaphoresis. before discontinuing
clonidine (prevents
clonidine withdrawal
hypertensive crisis).
Slowly reduce clonidine
dosage over 2–4 days.
After
o Consider the different
rights to drug
administration:
o Right Education
o Right Evaluation
o Right Documentation
 o To reduce hypotensive
effect, rise slowly from
lying to sitting position,
permit legs to dangle
momentarily before
standing.
o Skipping doses or
voluntarily
discontinuing drug may
produce severe,
rebound hypertension.

Mannitol Elevates blood Reduce pressure CNS: Headache, tremor, o Hypersensitivity, Before:
plasma osmolality, around the brain convulsions, dizziness, anuria, severe o Check the name on the
Therapeutic class: resulting in (high ICP) transient muscle rigidity. pulmonary edema or order and verify patient
Diuretics enhanced flow of heart failure, severe using two identifiers (as
water from tissues, CV: Edema, CHF, angina- dehydration, per hospital protocol)
Pharmacologic including the brain like pain, hypotension, metabolic edema, o Check the medication
class: and cerebrospinal hypertension, progressive renal label and order, the
osmotic diuretics fluid, into thrombophlebitis. disorder, active right dose of
interstitial fluid and intracranial bleeding medication, the right
Dosage: plasma. Eye: Blurred vision. (except during route, and the right time
150 cc IV q 4H craniotomy) of administration.
GI: Dry mouth, nausea, o Ask the patient about
vomiting. DRUG-DRUG history of any drug
INTERACTIONS allergies
Urogenital: Marked o Lithium: May increase o Perform physical
diuresis, urinary retention, urinary excretion of examination to assess
nephrosis, uricosuria. lithium. baseline status,
o Nephrotic drugs including weight,
Metabolic: Fluid and (aminoglycosides, before beginning
electrolyte imbalance, cyclosporine): may therapy and to
especially hyponatremia; increase risk of determine any potential
dehydration, acidosis. toxicity and renal adverse reactions
failure. o Provide a thorough
Other: With extravasation o Opioid analgesics: patient education
(local edema, skin may increase diuretic- regarding:
necrosis; chills, fever, related adverse effects o Drug and its mechanism
allergic reactions). and diminish of action
therapeutic effects of o Dosage of drug
diuretics. o Adverse effects of drug
 (headache, blurred
vision, and dizziness)
o Warning signs
o Safety precautions
o Careful evaluation must
be made of the
circulatory and renal
reserve prior to and
during administration of
mannitol – check for
the blood pressure.
o Measure I&O
accurately and record to
achieve proper fluid
balance.
o Prepare the medication
During:
o Administer drug
considering the drug
rights: route, drug,
dose, timing.
o Administer over 30-60
minutes
o Administer IV using
sterile, filter-type
administration set to
ensure against infusion
of mannitol crystals
o When administered
peripherally, infuse
slowly through a small-
bore needle, placed well
within the lumen of a
large vein to minimize
venous irritation;
carefully avoid
infiltration
o Do not mix with other
drugs
o Provide comfort
measures to help the
 patient cope with drug
effects.
o Provide patient
education about drug
effects and warning
signs to report to
enhance patient
knowledge and to
promote compliance.
After:
o Report any of the
following: Thirst,
muscle cramps or
weakness, paresthesia,
dyspnea, or headache.
o Family members should
immediately report any
evidence of confusion.
o Be alert to the
possibility that a
rebound increase in ICP
sometimes occurs about
12 h after drug
administration. Patient
may complain of
headache or confusion.
o Document
administration after
giving the ordered
medication. Chart the
time, route, and any
other specific
information as
necessary.
o Monitor for adverse
effects (e.g. infections,
skin changes, fatigue).
o Evaluate patient
understanding on drug
therapy by asking the
patient to name the
 drug, its indication, and
adverse effects to watch
for.
o Monitor patient
compliance to drug
therapy.

Dexamethasone Dexamethasone is a Acute o Contraindicated on CNS: euphoria, insomnia, Before:

highly potent and exacerbations of patients hypersensitive to psychotic behavior, 1. Check the name on the
Therapeutic class: long-acting cerebral edema drug or its ingredients, in pseudotumor cerebri, vertigo, order and verify patient
corticosteroids glucocorticoid those with systemic headache, paresthesia, using two identifiers (as
which acts as an fungal infections, and in seizures, depression per hospital protocol)
Pharmacologic anti-inflammatory those receiving CV: HTN, edema, 2. Check the medication
class: agent by immunosuppressive arrhythmias, thrombophlebitis, label and order, the
glucocorticoid suppressing doses together with live- thromboembolism right dose of
neutrophil virus vaccines. EENT: cataracts, glaucoma medication, the right
Dosage: migration, GI: peptic ulceration, GI route, and the right time
8mg IV now then decreasing o Use cautiously in irritation, increased appetite, of administration.
4mg IV q 6H production of patient’s sensitive to pancreatitis, nausea, vomiting 3. Ask the patient about
inflammatory sulfites because some GU: menstrual irregularities, history of any drug
mediators, forms contain sulfite increased urine glucose and allergies
reversing increased preservatives calcium levels 4. Perform physical
capillary Metabolic: hypokalemia, examination to assess
permeability, and hyperglycemia, carbohydrate baseline status,
suppressing Drug to Drug Interactions: intolerance, including weight,
immune response. Antidiabetics, including hypercholesterolemia, before beginning
It inhibits insulin: may decrease hypocalcemia, sodium therapy and to
accumulation of response. May need dosage retentions, weight gain determine any potential
inflammatory adjustment. Musculoskeletal: muscle adverse reactions
cells at Aspirin, indomethacin, other weakness, osteoporosis, 5. Provide a thorough
inflammation sites, NSAIDs: may increase risk tendon rupture, myopathy patient education
phagocytosis, of GI distress and bleeding. Skin: hirsutism, delayed regarding:
lysosomal enzyme Barbiturates, carbamazepine, wound healing, acne, various - Drug and its
release and phenytoin, rifampin: may skin eruptions, thin fragile skin mechanism of
synthesis, decrease corticosteroid Other: cushingoid state, action
and/or release of effect. susceptibility to infections, - Dosage of drug
mediators of Cardiac glycosides: may acute adrenal insufficiency - Adverse effects of
inflammation. increase risk of arrhythmia after increased stress or abrupt drug (drowsiness,
resulting from hypokalemia. withdrawal after long-term blurred vision, and
Therapeutic Effect: therapy, angioedema dizziness)
Prevents/suppresses - Warning signs
cell/tissue immune - Safety precautions
reactions,
inflammatory During:
process. 1. Administer drug
considering the drug
rights: route, drug,
dose, timing.
2. Protect the patient from
unnecessary exposure
to infection and
invasive procedures
because the steroids
suppress the immune
system and the patient
is at increased risk for
infection.
3. Provide comfort
measures to help the
patient cope with drug
effects.
4. Provide patient
education about drug
effects and warning
signs to report to
enhance patient
knowledge and to
promote compliance.

After:
5. Document
administration after
giving the ordered
medication. Chart the
time, route, and any
other specific
information as
necessary.
6. Monitor for adverse
effects (e.g. infections,
skin changes, fatigue).
7. Evaluate patient
 understanding on drug
therapy by asking the
patient to name the
drug, its indication, and
adverse effects to watch
for.
8. Monitor patient
compliance to drug
therapy.

Before:
Omeprazole Converted to used to treat Contraindications: None Side Effects • Observe rights of drug
active dyspepsia, a known. administration: right
metabolites that condition that Frequent (7%): Headache. patient, right drug right
Therapeutic class: irreversibly bind causes sour Caution: dosage, right route,
antiulcer drugs to, inhibit stomach, Occasional (3%–2%): right time.
hydrogen- belching, heart May increase risk of Diarrhea, abdominal pain, • Educate client about the
Pharmacologic potassium burn, or fractures gastrointestinal nausea. drug, its purpose and
class: PPIs adenosine indigestion. infections. Hepatic importance.
triphosphatase, impairment, pts of Asian Rare (2%): Dizziness, • Assess for possible
Dosage: an enzyme on descent. asthenia (loss of strength, contraindications and
the surface of Drug to Drug Interactions: energy), vomiting, cautions: history of
40 mg IV OD gastric parietal constipation, upper allergy to a proton
cells. Inhibits Ampicillin esters, azole respiratory tract infection, pump inhibitor to
hydrogen ion antifungals (such as back pain, rash, cough. reduce the risk of
transport into ketoconazole), erlotinib, iron
hypersensitivity
gastric lumen. derivatives, nilotinib: may Adverse Effects/ Toxic
reaction
cause poor bioavailability of Reactions
• Perform a physical
Therapeutic these drugs because they examination to establish
Effect: Increases need a low gastric pH for Pancreatitis, hepatotoxicity,
baseline data before
gastric pH, optimal absorption. interstitial nephritis occur
beginning therapy to
reduces gastric rarely.
determine the
acid production effectiveness of the
therapy and to evaluate
for the occurrence of
any adverse effects
associated with drug
therapy.

DURING:
 • Inspect and palpate the
IV insertion site for
signs of infection,
infiltration, or a
dislocated catheter.
• Inspect the surrounding
skin for redness, pallor,
or swelling.
• Palpate the surrounding
tissues for coldness and
the presence of edema,
which could indicate
leakage of the IV fluid
into the tissues.
• Clean the injection port
with the antiseptic
swab.
• Do not confuse Prilosec
(omeprazole) with
Prozac (fluoxetine) or
Pristiq
(desvenlafaxine). Do
not confuse omeprazole
with fomepizole.

After:
• Inspect the skin for
lesions, rash, pruritus,
and dryness to identify
possible adverse effects.
• Monitor other CNS side
effects (drowsiness,
fatigue, weakness,
headache), and report
severe or prolonged
effects.
• Monitor improvements
in GI symptoms
(gastritis, heartburn,
and so forth) to help
determine if drug
 therapy is successful.
• Instruct patient to report
bothersome or
prolonged side effects,
including skin problems
(itching, rash) or GI
effects (nausea,
diarrhea, vomiting,
constipation, heartburn,
flatulence, abdominal
pain).

Nicardipine Inhibits calcium ion Either alone or o Hypersensitivity to CNS: Dizziness or headache, Before:
reflux across with beta blockers nicardipine; advanced fatigue, anxiety, depression, 1. Check the name on the
Therapeutic class: cardiac and smooth for chronic, stable aortic stenosis parerethesias, insomnia, order and verify patient
antihypertensives muscle cells but is (effort-associated) somnolence, nervousness. using two identifiers (as
more selective to angina; either CAUTION: CV: Pedal edema, per hospital protocol)
Pharmacologic vascular smooth alone or with o CHF; renal and hepatic hypotension, flushing, 2. Check the medication
class: muscle than cardiac other impairment; palpitations, tachycardia, label and order, the
calcium channel muscle. Drug also antihypertensives Drug to Drug Interactions: increased angina. right dose of
blocker dilates coronary for essential GI: Anorexia, nausea, medication, the right
arteries and hypertension. Antihypertensives, protease vomiting, dry mouth, route, and the right time
Dosage: arterioles. inhibitors: may increase constipation, dyspepsia. Skin: of administration.
10 mg + 90 cc antihypertensive effect. Rash, pruritus. Body as a 3. Establish baseline data
PNSS at 5 cc/hr, Therapeutic Effect: Whole: Arthralgia or arthritis. before treatment is
titrate by 5 cc/hr to Significantly started including BP,
maintain SBP <150 decreases systemic pulse, and lab values of
mmHg vascular resistance. liver and kidney
It reduces BP at function.
rest and during 4. Monitor BP during
isometric and initiation and titration
dynamic exercise. of dosage carefully.
Hypotension with or
without an increase in
heart rate may occur,
especially in patients
who are hypertensive or
who are already taking
antihypertensive
medication.
During

1. Record and report any

increase in frequency,
duration, and severity
of angina when
initiating or increasing
dosage. Keep a record
of nitroglycerin use and
promptly report any
changes in previous
anginal pattern.
Increased incidence and
severity of angina has
occurred in some
patients using
nicardipine.
2. Do not change dosage
regimen without
consulting physician.
3. Be aware that abrupt
withdrawal may cause
an increased frequency
and duration of chest
pain. This drug must be
gradually tapered under
medical supervision.
4. Notify physician if any
of the following occur:
Irregular heart beat,
shortness of breath,
swelling of the feet,
pronounced dizziness,
nausea, or drop in BP.
5. Avoid too rapid
reduction in either
systolic or diastolic
pressure during
parenteral
administration.
6. Discontinue IV infusion
 if hypotension or
tachycardia develop.

After:
1. Document
administration after
giving the ordered
medication. Chart the
time, route, and any
other specific
information as
necessary.
2. Monitor for adverse
effects.
NURSING CARE PLAN

CUES NURSING SCIENTIFIC OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS RATIONALE
Subjective Elevated body Elevation of STO: INDEPENDENT INDEPENDE
cues: temperature related to inflammatory markers in After 2 hours- NT After 2 hours-
“mapaso iton the inflammatory the acute phase of 5hrs. of nursing 1. Identify the 1.Determination 5hrs.of nursing
iya lawas process as evidenced hemorrhagic stroke is a intervention, the triggering factors. and intervention, the
yana kay gin by increased HR and well-known client will able management of client’s
hihirantan respiratory rate. phenomenon and may to: the underlying temperature was
hiya” as result from infection •Decrease cause are decreased from
verbalized by with exogenous temperature to necessary to 38.7°C to 36. 5
wife microorganisms or from its normal range recovery. °C, and have a
the endogenous •maintain PR, normal finding of
Objective inflammatory response HR, BP within 2. To note the PR: 94bpm, HR
cues: 2.Monitor the progress and
of brain repair. Invading normal range. 20cpm but still
•Temp: patient’s temperature effectiveness of
inflammatory high in BP:
38.7C (36.5 HR, PR, and BP. medical
microorganisms such as 160/100 mmHg.
C) bacteria release treatment and GOAL WAS
•BP:180/90 pyrogens including observe the MET
mmHg lipopolysaccharide, changes in VS.
(120/80 peptidoglycans, and HR and BP
mmHg) muramyl peptides that increase as
•PR: 127bpm activate leukocytes to hyperthermia
(60-100 bpm) release endogenous progresses.
•RR: 35 cpm pyrogens, including the
(12-20 cpm) interleukins 1 and 6, 3.Room
3.Adjust and
•Flushed skin tumor necrosis factor-α temperature
monitor
•Warm to and interferon-γ. These may be
environmental accustomed to
touch cytokines trigger factors like room
•Right-sided liberation of arachidonic near normal
temperature and bed body
body acid from membrane linens as indicated. temperature and
weakness phospholipids,
•WBC Count: activation of blankets and
12.83 (4.8- cyclooxygenase, and linens may be
10.8) subsequent production adjusted as
•Neutrophils: of prostaglandins such indicated to
0.92 (0.43- as prostaglandin E2 regulate
0.65) (PGE2). Prostaglandin temperature of
E2 alters the the patient.
thermoregulatory set
point in the anterior
hypothalamus, and the 4.Provide tepid 4.May help
sympathetic response sponge baths, avoid reduce fever.
that ensues raises the use of alcohol. Use of ice
core temperature to the water/alcohol to
febrile set point. the skin can
cause chills; in
addition,
alcohol can be
drying to the
skin.

References:

Wrotek, S.Kozak,W. 5. Exposin

5. Eliminate
Hess, D. Fagan, S. g skin to room
excess
(2014,March air decreases
clothing and
15).Treatment of fever warmth and
covers.
after stroke:Conflicting increases
Evidence.https://www.n evaporative
cbi.nlm.nih.gov/pmc/arti cooling.\
cles/PMC3955174/

6. Raise the 6. This is

side rails at to ensure
all times. patient’s safety
even without
the presence of
seizure activity.

7. Educate 7. Providin
patient and family g health
members about the teachings to the
signs and symptoms patient and
of hyperthermia and family aids in
help in identifying coping with the
 factors related to the disease
occurrence of fever; condition and
discuss the could help
importance of prevent further
increased fluid complications
intake to avoid of
dehydration. hyperthermia.

DEPENDENT: DEPENDENT:

1. Administer 1.Paracetamol
paracetamol is an antipyretic
600mg IV as medication, it
ordered. helps lower
body
temperature by
blocking the
synthesis of
prostaglandins
that act in the
hypothalamus.

SUBJECTIV Ineffective tissue Ineffective tissue Short term INDEPENDENT INDEPENDEN Short term
E: perfusion related to perfusion describes objective: 1. Determine factors T objective:
“Naglilipong Insufficient blood the lack of oxygenated Within 8 hours related to individual 1. Influences Within 8 hours of
adto an iya flow/ Interruption in blood flow to areas of of nursing situation, cause for choice of nursing
intervention, the
ulo tapos tas blood flow to organs the body. Proper intervention, the coma, and potential interventions.
patient was able to:
tigda la and tissues perfusion is detrimental patient will be for increased For example, ➢ Demonstrat
nanluya an to the function of organs able to: intracranial pressure treatment of a e stable
right side han and body systems as • Demons (ICP). patient with vital signs
iya lawas” as organs and tissues that trate acute and
verbalized by are not perfusing will stable hemorrhagic absence of
the wife die. vital stroke depends signs of
signs on the cause increased
OBJECTIVE: and and severity of ICP.
CT scan absence bleeding. Basic ➢ BP:
•reveals left of signs life support, as 160/100
capsuganglion of well as control ➢ HR: 94
➢ RR:20
ic bleed increase of bleeding,
➢ O2: 95%
•BP: 180/90 d ICP. seizures, blood
➢ (+) right
(high) pressure (BP), sided body
N: 120/80 Long term and intracranial weakness
•O2 sat: 90% objective: pressure, is GOALS
(low) Within 3 critical. PARTIALLY
N: 95-100% months of Deterioration in MET
•HR: 127 nursing neurological Long term
(high) intervention, the signs and objective:
N: 60-100 patient will be symptoms or Within 3 months of
•POTASSIU able to: failure to nursing
M: 3.17 (low) • Maintai improve after intervention, the
N: 3.5-5.3 n usual initial insult patient was not able
to:
•FBS: 9.06 or may reflect
➢ Maintain
(high) improve decreased usual or
N: 4.1-6.6 d LOC, intracranial improved
•HDL Ratio: cognitio adaptive LOC,
4.75 (high) n, and capacity, which cognition,
N: 2.94-4.62 motor requires that and motor
•Total and client be and sensory
Cholesterol: sensory admitted to function
8.31 (high) function critical care ➢ Display no
N: 3.6-5.7 • Display area for further
•LDL monitoring of deterioratio
no
n or
Cholesterol: further ICP and for
recurrence
6.35 (high) deteriora specific of deficits
N: 1.66-3.89 tion or therapies geared ➢ GCS score
• (+) right recurren to maintaining 10
sided body ce of ICP within a ➢ (+) right
weakness deficits specified range. sided body
•GCS score: If the stroke is weakness
10 evolving, the ➢ (+) aphasia
• (+) aphasia client can ➢ (+)
• (+) deteriorate dysphagia
dysphagia quickly and GOAL NOT MET
 require repeated
assessment and
progressive
treatment. If the
stroke is
“completed,”
the neurological
deficit is
nonprogressive,
and treatment is
geared toward
rehabilitation
and preventing
recurrence.

2. Monitor and 2. Assesses

document trends in level
neurological status of
frequently and consciousness
compare with (LOC) and the
baseline. potential for
increased ICP
and is useful in
determining
location, extent
of central
nervous system
(CNS damage).

Monitor vital signs

noting: 3. Fluctuations
3. Hypertension or in pressure may
hypotension; occur because
compare blood of cerebral
pressure (BP) pressure or
readings in both injury in the
arms vasomotor area
of the brain.
 Hypertension
may have been
a precipitating
factor in the
stroke, and
hypotension
may follow
stroke because
of circulatory
collapse.

4. Heart rate and 4. Changes in

rhythm; auscultate rate, especially
for murmurs. bradycardia,
can occur
because of the
brain damage.
Dysrhythmias
and murmurs
may reflect
cardiac disease,
which may have
precipitated
CVA, for
example, stroke
after MI or from
valve
dysfunction

5. Respirations, 5. Irregularities
noting patterns and can suggest the
rhythm— periods of location of
apnea after cerebral insult
hyperventilation, or increased
Cheyne- Stokes ICP and need
respiration. for further
intervention,
including
possible
 respiratory
support.

6. Evaluate pupils, 6. Pupil

noting size, shape, reactions are
equality, and light regulated by the
reactivity oculomotor (III)
cranial nerve
and are useful
in determining
whether the
brainstem is
intact. Pupil
size and
equality are
determined by
the balance
between
parasympathetic
and sympathetic
enervation

7. Document 7. Specific
changes in vision, visual
such as reports of alterations
blurred vision and reflect the area
alterations in visual of brain
field or depth involved,
perception. indicate safety
concerns, and
influence choice
of interventions.

8. Assess higher 8. Changes in

functions, including cognition and
speech, if client is speech content
alert. are an indicator
of location and
 degree of
cerebral
involvement
and may
indicate
increased ICP.

9. Assess for nuchal 9. Indicative of

rigidity, twitching, meningeal
increased irritation,
restlessness, especially in
irritability, and onset hemorrhagic
of seizure activity. disorders.
Seizures may
reflect increased
ICP or reflect
location and
severity of
cerebral injury,
requiring
further
evaluation and
intervention.

10. Position with the 10. Reduces

head of bed elevated arterial pressure
to 30 degrees, and by promoting
maintain head in venous drainage
neutral position. and may
improve
cerebral
circulation and
perfusion.

11. Prevent straining 11. Valsalva’s

at stool or holding maneuver
breath. increases ICP
and potentiates
 risk of bleeding.

DEPENDENT: DEPENDENT:
1. Administer 1. Reduces
supplemental hypoxemia.
oxygen, as indicated.

2. Administer 2. Treatments
medication as (including
ordered medications)
depend on the
cause of the
stroke (i.e.,
ischemic or
hemorrhagic)
and
management of
- Atorvastatin 40 mg associated
OD HS symptoms and
under lying
conditions

- Primary
prevention of
cardiovascular
disease in high
- Amlodipine risk pts.
5mg/tab 1 tab OD Reduces risk of
stroke in pts
with or without
evidence of
- Clonidine heart disease
75mg/tab 1 tab TID with multiple
risk factors
other than
diabetes.
- Mannitol 150 cc IV
 q 4H - Decreases
total peripheral
- Dexamethasone vascular
4mg IV q 6H resistance and
B/P by
vasodilation.

- Treatment of
hypertension
alone or in
combination
with other
antihypertensiv
e agents

- Reduce
pressure around
the brain (high
ICP)

- Acute
exacerbations of
cerebral edema

Subjective: Decreased cardiac High blood pressure STO: Within 8 Independent: STO: Within 8
“Nalilingaw output related to adds to the heart’s hours of nursing ●Measure BP in ●Serial hours of nursing
ito hiya inadequate oxygenated workload. Narrowed intervention, the both arms. Take measurements intervention, the
danay, as blood pumped by the arteries that are less patient will be three readings, 3 to 5 using correct patient was not be
verbalized by heart elastic make it more able to: minutes apart while equipment able to:
the wife. difficult for blood to ● Participate in client is at rest, then provide more ● Participate in
travel efficiently activities that sitting, and then complete activities that
Objetive: throughout the body. reduce standing for initial picture of reduce BP/cardiac
•CT scan Increase in blood BP/cardiac evaluation. vascular workload.
reveals left pressure adds to the workload. involvement ● Participate in
capsuganglion workload of the heart ● Participate in and scope of activities that will
ic bleed and arteries. If it activities that problem. prevent stress
continues for a long will prevent Systolic (stress
BP results as time, the heart and stress (stress hypertension management,
follows: arteries may not function management, also is an balanced activities
(08/30/22) properly. If the blood balanced established risk and rest plan).
BP: 230/110 pumped by the heart activities and factor for CVD ● Demonstrate
N: 120/80 does not meet the rest plan). even when improved cardiac
(08/31/22) metabolic demands of ● Demonstrate diastolic rhythm and rate.
BP: 190/120 the body, decreased improved pressure is not ➢ BP:
N: 120/80 cardiac output results. cardiac rhythm elevated. 160/100
(09/01/22) and rate. ➢ HR: 94
BP: 220/100 ●Note presence and ●Bounding ➢ RR:20
N: 120/80 quality of central carotid, jugular, ➢ O2: 95%
(09/02/22) and peripheral radial, and GOALS NOT
BP: 180/90 pulses. femoral pulses MET
N: 120/80 American Heart may be
Association (2022), How observed and
• O2 sat: 90% Blood Pressure Can palpated. Pulses
(low) Lead to Decreased in the legs and
N: 95-100% Cardiac feet may be
• HR: 127 Output.http://www.heart diminished,
(high) .org/en/health-topics reflecting
N: 60-100 effects of
vasoconstriction
and venous
congestion.

●Auscultate heart ●S4 is

tones and breath commonly
sounds. heard in
severely
hypertensive
clients because
of the presence
of atrial
hypertrophy.
Development of
S3indicates
ventricular
hypertrophy and
impaired
cardiac
functioning.
●Observe skin color, ●Presence of
moisture, pallor; cool,
temperature and moist skin; and
capillary refill time. delayed
capillary refill
time may be
due to
peripheral
vasoconstriction
or reflect
cardiac
decompensation
and decreased
output.

●Observe for ●May indicate

dependent and onset of heart or
generalized edema. kidney failure.

●Maintain activity ●Reduces

restrictions (such as physical stress
bedrest and chair and tension that
rest) during crisis affect BP and
situation and the course of
schedule periods of hypertension.
uninterrupted rest;
assist client in self-
care activities as
needed.

●Provide comfort ●Decreases

measures, such as discomfort and
back and neck may reduce
massage or elevation sympathetic
of head. stimulation.

●Response to
●Monitor response drug therapy is
 to medications that dependent on
control BP. both the
individual drugs
and their
synergistic
effects. Because
of potential side
effects and drug
interactions, it
is important to
use the smallest
number and
lowest dosage
of medications
possible.

Collaborative:
●Administer anti- ●Antihypertensi
hypertensive ve agents as
medications, as well, by
ordered. limiting fluid
retention, and
may reduce the
incidence of
strokes and
heart failure.
Subjective: Impaired Physical A stroke is an upper STO: After 8 Independent: STO: After 8
“nanluluya Mobility related to motor neuron lesion and hours of nursing ● Assess ● Identifies hours of nursing
iton iya tuo na right hemiparesis results in loss of intervention, the functional strengths intervention, the
lawas” as secondary to CVD voluntary control over patient will ability and and patient
verbalized by movements. The most ●Maintain skin extent of deficiencies ●Was able to
the wife. common motor integrity impairment and may Maintained skin
dysfunction is ●demonstrate initially and on provide integrity
hemiplegia (paralysis of techniques or a regular basis. information ●was not able
Objective: one side of the body, or behaviors that regarding demonstrated
●Limited part of it) caused by a enable ● Teach patient or recovery. techniques or
range of lesion of the opposite resumption of assist with behaviors that
motion side of the brain. activities passive ROM ● Exercise enable resumption
●Right sided Hemiparesis, or exercises of enhances of activities
weakness weakness of one side of LTO: After 3 extremities, as increased GOALS
noted. the body, or part of it, is days of nursing tolerated. venous PARTIALLY
●Unable to do another sign. interventions, return, MET
ADL’s ●Client will prevents
●POTASSIU Reference: Brunner increase stiffness, LTO: After 3
M: 3.17 Suddarths Textbook of strength/functio and days of nursing
(low)N: 3.5- Medical-Surgical n of affected maintains interventions,
5.3 Nursing 14th Edition by and muscle client was not
Dr. Janice L. Hinkle, compensatory strength able to
Kerry H. Cheever Page body parts. and ●increased
5271 ●Client will be stamina. It strength/function
able to ● Promote and also avoids of affected and
demonstrate facilitate early contracture compensatory
increase ambulation deformatio body parts.
mobility. when possible. n, which ● to demonstrate
Aid with each can build increase mobility.
initial change: up quickly Limited range of
dangling legs, and could motion
sitting in chair, hinder ●Right sided
ambulation. prosthesis weakness noted.
usage. ●Unable to do
ADL’s
● These
● Let the patient movements GOALS NOT
accomplish keep the MET
tasks at his or patient as
her own pace. functionally
Do not hurry the working as
patient. possible.
Encourage Early
independent mobility
activity as able increases
and safe. self-esteem
about
reacquiring
● Provide the independen
patient of rest ce and
periods in reduces the
between chance that
 activities. debilitation
Consider will
energy-saving transpire.
techniques.
● Healthcare
providers
and
● Turn and significant
position the others are
patient every 2 often in a
hours or as hurry and
needed. do more for
patients
than
● Help patient in needed.
accepting Thereby
limitations. slowing the
patient’s
recovery
and
reducing
his or her
confidence.

● Rest
periods are
essential to
● Teach patient or conserve
family in energy. The
maintaining patient
home must learn
atmosphere and accept
hazard-free and his her
safe. limitations.

● Position
changes
Collaborative: optimize
● Consult with circulation
physical to all
therapist tissues and
regarding relieve
active, resistive pressure.
exercises and
client
ambulation. ● Let the
patient
understand
and accept
Source: Nursing his or her
Care Plans, Edition limitations
9 - Murr, Alice, and
Doenges, Marilynn, abilities.
Moorehouse, Mary Assistance,
on the other
hand, needs
to be
balanced to
prevent the
patient
from being
unnecessari
ly
dependent.

● A safe
environmen
t will help
prevent
injury
related to
falls.
● Individualiz
ed program
can be
developed
to meet
particular
needs and
deal with
deficits in
balance,
coordinatio
n, and
strength.

Source: Nursing
Care Plans,
Edition 9 -
Murr, Alice,
Doenges,
Marilynn,
Moorehouse,
Mary
Subjective: Noncompliance Noncompliance occurs After 8 hours of Independent: After 8 hours of
“Diri la anay related to lack of when a patient (family, nursing 1. Develop a 1.This nursing
kami mapa knowledge/understan caregiver, guardian) fails intervention, the therapeutic allows the intervention, the
insert hin ding/motivation/skill to adhere to a healthcare patient and his relationship patient to mother patient
catheter, provider’s wife will be gain trust and SO
between and
pwede man recommendations or able to: from the ● was not able
among the
hiya prescribed treatment ●Demonstrate a nurse and Demonstrate a
patient and
magdiaper la plan. This can include commitment to will boost commitment to
significant
anay” as medications, procedures, improving confidence improving health
others. status by
verbalized by follow-up appointments, health status by in the
the wife. and lifestyle completion implementing
implementing
modifications. of the positive behaviors
positive
“diri gihap Poor adherence to treatment. (not missing doses
behaviors (not of medications,
kami mapa healthcare missing doses
butang hin recommendations, keeping
of medications, appointments)
NGT kay medications, and
keeping ●Was able to
hulaton ko pa treatments is directly 2. Patients or
appointments) 2. Determine the Verbalized an
an iya bugto” related to poorer family
●Verbalize an patient’s/families understanding of
as verbalized outcomes, lower quality members
by wife. of life, and higher understanding ’ perception of their health status
of their health who do not and list changes
healthcare costs. their condition. have a
“diri gihap status and list required to
changes thorough improve their
kami mapa
required to understandi adherence
butang hin
improve their ng of their GOALS
tubo” as
verbalized by adherence health and PARTIALLY MET
wife related
●Expression Long term goal outcomes Long term goal:
of disinterest, after 1 month of may not be ●was able to
distrust and nursing committed access resources in
denial. intervention, the to the plan order to improve
of care. compliance
patient and
They may GOAL MET
“Danay di wife:
nainom kay -Access not be
nainom resources in aware of
naman hin order to long-term
herbal sugad improve effects or
hin pansit- compliance realize the
pansitan ngan severity of
guyabano their
leaves. Gin disease.
iinom ini niya
kun nasakit 3. Assess the 3. Views on
iya tiil. Kun patient’s maintenance
nagkakaada understanding vary from
kwarta, danay about his or her each patient.
nainom hiya current condition Some may
hito na and the
Telmisartan,” base it on
importance of religious
as verbalized health care.
by the wife beliefs and
●Noncomplia refuse
nce to medical
maintenance treatments.
medication Other may
consider
Objective: natural
• SO signed remedies.
the This
consent to approach
refuse will provide
FBC and a basis for
NGT planning
insertion future care.
• SO signed 4. Assess who is in
waiver of charge of the 4. Patients
refusal or patient’s care, if may leave
‘E’ not them. their
intubation healthcare
• Poor up to their
complianc spouse or
e to adult
antihypert children.
ensive Confer with
medicatio the person
n in charge to
prevent
miscommun
ication or
gaps in care.

5. Inquire about 5. Patients are

medications often
noncomplia
nt with
medications
which in
turn leads to
exacerbatio
ns or
worsening
of their
health
conditions.
Obtain a
thorough list
of
medications
and ask
specific
questions
about how
many doses
have been
missed in a
two-week
timeframe.
Inquire
about
reasons why
such as
 frequency,
cost, or side
effects.
6. Assess for cost
or resource 6. Some
limitations. patients live
in rural
areas with
limited
access to
specialists
or
transportatio
n to get to
care centers.
The cost
burden of
medications
and
treatments
may be too
much for a
disabled or
elderly
patient,
even with
insurance.
These
situations
can be a
source of
shame and
patients may
not be
forthcoming
with these
reasons for
 not
adhering.

7. Provide non- 7. Healthcare

judgmental professional
listening. s can often
perceive
noncomplia
nce as the
patient
simply
making a
choice to
not follow
recommend
ations.
Allow the
patient time
and space to
discuss their
reasons. A
trusting and
nonjudgmen
tal
relationship
allows for
the best
possibility
of
improving
adherence.

8. Inquire
8. Ensure
about the
information is
patient’s
provided at their
learning
developmental
style and
 level. how they
like to
receive
information.
Give
information
in
manageable
amounts and
limit the use
of medical
jargon.
9. Educate the
patient and the
9. This
family members
increases
on the treatment
awareness
regimen that the
about the
patient will
importance
undergo.
of
completing
the
prescribed
treatment. It
provides
increased
compliance
to such
treatment.

10. Provide specific 10. Information

instructions as allows the
indicated. patient to
better take
control in
selecting
 and
implementin
g required
changes in
behavior.

11. Ensure 11. Patients are

continuity of more likely
care. to complete
follow-up
appointment
s if they are
scheduled
prior to
discharge.
The use of
inpatient
pharmacies
that deliver
to the
patient’s
room before
discharging
home
prevents
them from
not picking
up a new
medication
at their own
pharmacy.

12. If the cost of

12. Direct to
medications
community
is a barrier,
resources.
provide
information
 on patient
assistance
programs or
Rx savings
cards. Local
services
assist with
preventative
healthcare
services,
insurance
assistance,
medical
equipment
and
supplies,
and
transportatio
n.

Dependent:
1. Administer Administering
the following the medications
medications or treatment
as per with proper
doctor’s education can
order: enhance the
- Atorvastatin 40 mg patient/SO
OD HS adherence to
therapeutic
regimen.

- Amlodipine
 5mg/tab 1 tab OD

- Clonidine
75mg/tab 1 tab TID

- Mannitol 150 cc IV
q 4H

- Dexamethasone
4mg IV q 6H

Collaborative:
1. Evaluate Compliance
compliance via with
lab results medications can
be evaluated by
lab results.
Subjective: Risk for impaired During a stroke, certain STO: After 1-2 Independent Independent STO: After 1-2
“Diri skin integrity parts of your brain do days 1. Inspect all skin 1.Skin is days of
pa ito niya related to not get enough oxygen, of nursing areas, noting especially prone nursing
kaya bis hemiparesis and causing the cells to die. intervention, the capillary blanching to breakdown intervention, the
lumingkod ha decreased If these parts are client and refill, because of client was able to:
higdaan, asya mobility associated with body will be able to: redness, and changes Identify
naghinigdaon strength and Identify swelling. in peripheral individual
risk factors.
la ito movement, damaging individual risk circulation,
Verbalize
hiya” as them can cause factors. 2. Check on bony inability to
understanding of
verbalized hemiparesis. Verbalize prominences such as sense treatment needs.
by the wife. Hemiparesis is a understanding the sacrum, pressure, Participate to
Objective: common after-effect of of treatment trochanters, immobility, and level
Right sided stroke that causes needs. scapulae, elbows, altered of ability to
weakness weakness on one side Participate to heels, inner and temperature prevent skin
Bed rest for of the body. Physical level of ability outer malleolus, regulation.
5 days immobility, prolonged to prevent skin inner and outer breakdown.
Immobile bed rest, alterations in breakdown. knees, back of 2.Specific areas
nutritional status often head). where skin LTO: After 3
result in impaired LTO: After 3 is stretched months of
peripheral circulation, months 3. Encourage tautly are at nursing
compromising the of nursing continuation of higher risk for intervention, the
tissue nutrient delivery intervention, the regular exercise breakdown client was not
able to:
and skin integrity. client program, as because the
Patient
will: tolerated. possibility of
demonstrates
Patient ischemia to understanding of
Brown, A &amp; demonstrates 4. Elevate lower skin is high as a plan to heal tissue
Carmuciano,K. (2003). understanding extremities result of and prevent
Stroke Recovery and of plan to heal periodically, if compression of injury.
Rehabilitation. tissue and tolerated. skin GOALS
Education handout. prevent injury. capillaries PARTIALLY
5. Massage and between a MET
lubricate skin with hard surface
bland lotion or oil. (e.g.,
Protect pressure mattress, chair,
points by use of or table)
elbow or heel pads, and the bone.
lamb’s wool,
foam padding, and 3.Exercise
egg-crate mattress or stimulates
cushion. circulation that
enhances
6. Reposition cellular
frequently, whether nutrition and
in bed or in sitting oxygenation.
position. Place in
prone position 4.Elevation of
periodically, if not lower
contraindicated extremities
by respiratory status. enhance
venous return
7. Wash and dry and
skin, reduces edema
especially in high- formation.
moisture areas such
as perineum. 5.Skin care and
massage
8. Keep bedclothes enhance
dry circulation and
and free of wrinkles, protect skin
crumbs, and creases. surfaces, thus
reducing
Collaborative: risk of pressure
1. Provide kinetic ulcers.
therapy or
alternating-pressure 6.Repositioning
mattress as improves
indicated. skin circulation
and
reduces
pressure
on bony
prominences.

7.Clean, dry
skin is less
prone to
excoriation or
breakdown.

8.Preventing
excessive
moisture and
friction
reduces skin
irritation.

COLLABORA
TIVE
1. Kinetic
therapy and
alternating-
pressure
 mattress
improves
systemic and
peripheral
circulation and
reduces
pressure on
skin and risk for
breakdown.
Subjective Caregiver Role Strain Shock, helplessness, and STO: Independent Independent STO:
Cue: related to severity of worry are common After 8 hours of 1.Establish rapport. 1.To build trust After 8 hours of
“Natigdaan illness of the care among stroke survivors nursing and connection nursing
man gud ako receiver and their loved ones. interventions, with the patient. interventions, the
hini na iya Right after a stroke, it's the caregiver 2.Note physical and caregiver was
kabutangan, not unusual to feel will be able to: psychosocial 2.Careful able to:
tigda ako na overwhelmed, uncertain condition. Identify assessment of
tanan bisan and even fearful about 1.Identify client ability to physical and 1. Ide
ntify
pagliwan hit your new role as a individual risk comply with psychosocial
individual
iya bado ngan caregiver — perhaps factors and therapeutic regimen. conditions
risk factors
pampers ngan because of severe appropriate determines and
pag aalsa. physical limitations or interventions. individual needs appropriat
Aadi gad it personality changes in 2.Display 3.Determine for planning e
akon anak your loved one. The improved well- caregiver’s level of care and helps interventio
pero ako la caregiver has to balance being such as commitment, identify ns.
gihap it a dual responsibility of improvements responsibility, strengths and 2. Dis
nagios tanan" looking after a in mood and involvement, and needs requiring played
as verbalized dependent stroke coping. anticipated length of assistance and improved
by the wife. survivor as well as 3.Demonstrated care. accommodation well-being
making adjustments in initiate of intervention. such as
Objective his or her lifestyle. behaviors or 4.Discuss improveme
Cues: Hence, due to its lifestyle caregiver’s view of nts in
- Husba debilitating and chronic changes to the situation. 3.Progressive mood and
nd suffering nature, caring for stroke prevent debilitation coping.
stroke survivors often puts development of taxes caregiver 3. De
- Restle considerable burden on impaired 5.Determine and may alter monstrate
ssness their caregivers. function. available resources ability to meet d initiate
- Irritabi 4.Use available and client’s and behaviors
lity American Stroke resources social support. own needs. or lifestyle
changes to
- Fatigu Association appropriately
e https://www.stroke.org/- 5.Report 6.Facilitate family 4.Discuss prevent
- Avoidi /media/Stroke- satisfaction with conference to share caregiver’s developm
ng eye contact Files/Caregiver- plan and information and view of the ent of
- Poor Support/Caregivers- support develop plan for situation. impaired
communicatio Guide-to- available involvement in care function.
n Stroke/CaregiverGuideT activities, as 4. Us
oStroke_2020.pdf appropriate. 5.Organizations e
, such as the available
local support resources
appropriat
7.Emphasize groups can
ely
importance of self- provide
5. Re
nurturing, such as information port
pursuing self- regarding satisfaction
development adequacy of with plan
interests, personal supports and and
needs, hobbies, and identify needs support
social activities and possible available
options.
8.Assist with short- GOALS NOT MET
term and long-term 6.Family
care planning to conference
meet the current and helps clarify
future needs of the different roles
recipient of care, and
responsibilities,
facilitates
Collaborative: coping, and
1. Refer to promotes
supportive participation
services, as and
indicated. involvement.

7.Taking time
for self can
lessen risk of
burnout or
being
overwhelmed
by situation.
 8.Short-term
and long-term
care planning
provides
ongoing
assessment and
evaluation of
client needs and
clinical
outcomes and
realization of
changes in the
level of care

Collaborative
1.Medical case
manager or
social services
consultant may
be needed to
develop
ongoing plan to
meet changing
needs of client
and SO/family.
Subjective Risk for fall related to A hemorrhagic stroke STO: INDEPENDENT: After all the nursing
Cues: neuromuscular occurs when blood leaks interventions the
1. Assess history of 1. Individuals
“Dire na niya involvement: from a burst, torn, or Within 5 to 8 client was able to
kaya makiwa weakness, paralysis unstable blood vessel hours of falls. are more
ngan (initially) as evidence into the brain tissue. The interventions likely to fall a. Remained free
nanluluya it by right-sided body buildup of blood can the client will: again if they from falls during
iya tuo nga weakness create swelling and have hospital stay.
parte hit iya pressure, which can lead a. Remain sustained one
2. Assess mental b. Understood the
lawas.” As to brain damage free or more falls
intent to use
verbalized by especially on the left from in the past six
the wife. hemisphere side f the falls status changes. months. safety measures
brain which can cause during to prevent fall
2. Persons with
Objective right-sided body hospital
Cues: weakness which stay. impaired c. Implemented
3. Assess the
awareness strategies to
• Weak predispose a person of b. Underst patient’s balance
ness having a higher risk of and the and increase safety
and gait.
• Dizzin fall. intent to disorientation and prevent
ess use may not falls with the
• Right Reference: safety understand help of his
4. Review the where they family
sided-body https://www. measure
patient’s are or what to
weakness Medicalnews s to
medications. GOAL MET
• Limite today.com/ prevent do to help
d ROM articles/313 falls themselves.
596#types-and-causes c. Impleme
3. Stroke
nt
strategie patients
5. Design an altered
s to
individualized plan balance and
increase
of care for difficulty in
safety
preventing falls. walking due
and
Provide a plan of to certain
prevent
falls care that is effect to the
with the individualized to brain which
help of the patient’s controls the
his unique needs. balance and
family 6. Transfer the gait.
patient to a room 4. Risk factors
near the nurses’ for falls also
station. include
medication
use such as
7. Place beds are at antihypertens
the lowest possible ive agents,
position. Set the ACE-
patient’s sleeping inhibitors,
surface as near the diuretics,
floor as possible if tricyclic
 needed. antidepressan
ts, alcohol
8. Raise side rails on
use,
beds, as needed.
antianxiety
For beds with split
agents,
side rails, leave at
opiates, and
least one of the
hypnotics or
rails at the foot of
tranquilizers.
the bed down.
5. Planning an
9. Ask the family to
individualized
stay with the
fall
patient.
prevention
program is
essential for
COLLABORATIVE: nursing care
in any
healthcare
1. Collaborate with environment
other health care and needs a
team members to multifaceted
assess and approach.
evaluate patients’
medications that
contribute to
falling. Examine
peak effects for
prescribed
6. Determining
medications that
which
affect the level of
patients are
consciousness.
most likely to
2. Allow the patient fall is
to participate in a essential to
program of regular prepare and
exercise and gait anticipate
training. nearby
location and
 provide more
constant
observation
and quick
response to
call needs.

7. Keeping the
beds closer to
the floor
reduces the
risk of falls
and serious
injury. Placing
the mattress
on the floor
significantly
reduces fall
risk in some
healthcare
settings.

8. According to
research, a
disoriented or
confused
patient is less
likely to fall
when one of
the four rails
is left down.

9. Helps prevent
the patient
 from
accidentally
falling or
pulling out
tubes.

1. A review of
the patient’s
medications
by the
prescribing
health care
provider and
the
pharmacist
can identify
side effects
and drug
interactions
that increase
the patient’s
fall risk. The
more
medications
a patient
takes, the
greater the
risk for side
effects and
interactions
such as
dizziness,
orthostatic
 hypotension,
drowsiness,
and
incontinence.

2. Studies
recommend
exercises to
strengthen
the muscles,
improve
balance, and
increase
bone density.
Increased
physical
conditioning
reduces the
risk for falls
and limits
injury that is
sustained
when fall
transpires

Objective Impaired Verbal Aphasia is a language STO: After 8 Independent Independent STO: After 8 hours
Cues: Communication disorder that affects your hours of nursing of nursing
1. Assess type and 1. Helps
“Kinukurian related to impaired ability to communicate. interventions, interventions, the
ito hiya motor function of It's most often caused by the patient will degree of dysfunction determine area
patient was able to:
pagyakan,” as muscles of speech strokes in the left side of be able to: and degree of
2. Listen for errors in 1. Indicate
verbalized by secondary to CVD. the brain that control 1. Indicate brain
conversation and understanding of
the wife. speech and language. understanding involvement and
provide feedback the communication
People with aphasia may of the difficulty client
problems.
Subjective struggle with communication 3. Ask client to follow has with any or
Cues: communicating in daily problems. simple commands, all steps of the 2. Establish
• CT scan activities at home, 2. Establish such as “Shut your communication method of
reveals left socially or at work. They method of eyes,” “Point to the communication in
capsuganglion may also feel isolated. communication door”; repeat simple process which needs can be
ic bleed Aphasia doesn't affect in which needs words or sentences. expressed.
2. Client may lose
• As intelligence. Stroke can be
survivors remain expressed. 4. Point to objects ability to monitor 3. Use resources
September 04,
mentally alert, even 3. Use resources and ask client to name verbal output appropriately.
2022: GCS of
7 (Verbal though their speech may appropriately. them. and be unaware GOALS WERE
response – be jumbled, fragmented that PARTIALLY MET
5. Have client produce
incomprehens or hard to understand. communication is
simple sounds, such as
ible sounds) not sensible.
“sh,” “cat.”
• Stuttering 3. Tests for
noted 6. Ask client to write
receptive
• Slurred name and/or a short
aphasia.
speech sentence. If unable to
write, have client read 4. Tests for
a short sentence. expressive
aphasia—client
7. Post notice at
may recognize
nurses’ station and
item but not be
client’s room about
able to name it.
speech impairment.
Provide special call 5. Identifies
bell if necessary. dysarthria
because motor
8. Provide alternative
components of
methods of
speech (tongue,
communication, such
lip movement,
as writing or felt
breath control)
board and pictures.
can affect
Provide visual clues—
articulation and
gestures, pictures—”
may or may not
needs” list, and
be accompanied
demonstration.
by expressive
9. Anticipate and aphasia.
provide for client’s
6. Tests for
needs
writing disability
10. Talk directly to (agraphia) and
client, speaking slowly deficits in
and distinctly. Use reading
yes/no questions to comprehension
start, progressing in (alexia), which
complexity as client are also part of
responds. receptive and
expressive
11. Speak with normal
aphasia.
volume and avoid
talking too fast. Give 7. Allays anxiety
client ample time to related to
respond. Talk without inability to
pressing for a communicate
response. and fear that
needs will not be
12. Encourage SO and
met promptly.
visitors to persist in
efforts to 8. Provides for
communicate with communication
client, such as reading of needs or
mail and discussing desires based on
family happenings individual
even if client is unable situation or
to respond underlying
appropriately deficit.

13. Discuss familiar 9. Helpful in

topics—job, family, decreasing
hobbies, and current frustration when
events. dependent on
others and
14. Respect client’s
unable to
preinjury capabilities;
communicate
avoid speaking down
desires.
to client or making
patronizing remarks. 10. Reduces
confusion and
anxiety at having
Collaborative to process and
respond to large
1. Consult with or amount of
refer to speech information at
therapist. one time.

11. Client is not

necessarily
hearing impaired
and raising voice
may irritate or
anger client.

12. It is
important for
family members
to continue
talking to client
to reduce client’s
isolation,
promote
establishment of
effective
communication,
and maintain
sense of
connectedness
with family.

13. Promotes
meaningful
conversation and
provides
opportunity to
practice skills.

14. Enables
client to feel
esteemed
because
intellectual
 abilities often
remain intact.

Collaborative

1. Assesses
individual verbal
capabilities and
sensory, motor,
and cognitive
functioning to
identify deficits
and therapy
needs.

Subjective Ineffective Family Ineffective processes are STO Independent Independent After 8-10 hours of
cues: Processes related to the inability to manage, After 8-10 nursing
1. Assess for 1. Dependi
illness of a family respond to, or make hours of nursing intervention,
“dire na ako member decisions surrounding a intervention, precipitating ng on the
caregiver was not
maaram kon stressful situation. caregiver will factor (eg. stressor,
able to:
ano’t akon Stressors and everyday able to: Illness, life a variety
bubuhaton demands such as, family -verbalize transition of •verbalized
labi na yana needs. An increase stress appropriate crisis) strategie appropriate coping
na nakastroke an unable to accept the coping s may be strategies and
2. Assess family
hiya, tungod situation may increase strategies and required resources.
members
glucocorticoid release resources. to
manngud na perceptions •Identified
which may results to -Identifies facilitate
hiya permi it on problem. resources available
disturbed thought resources coping.
akon for problem-solving
processes or unable to available for 3. Evaluate
kabakyang 2. Resolutio
think or decide then may problem solving strengths, •expressed
kon mayda lead to altered family -express ns is
coping skills confidence in
kami processes. confidence in possible
and current handling their
problema ha ¤ handling their only if
support stressors and when
balay”, as stressors and each
system. to ask for help
verbalized by when to ask for person
the wife. help 4. Explain perceptio GOAL NOT MET
procedures, n are
Objective diseases understo
cues: processes, od. And
-Incapacity to and next understa
cope with steps. nding
crisis another’s
-Unable to 5. Provide
perceptio
decide opportunities
n can
-Insufficient to express
lead to
skills to meet concerns,
clarificati
goals, fear,
on and
problem-solve expectations
problem
or reach or questions.
solving
resolutions
6. Assist the
-Behaviors 3. This
caregiver in
that impede facilitate
setting
progress s the use
realistic goals.
(defensive of
speech, 7. Identify previous
making community y
excuses, resources that successfu
manipulation) may be l
Inability to helpful in techniqu
handle life dealing with es.
responsibilitie particular
s while also 4. Offering
situations
maintaining a
boundaries thorough
informati
on
regarding
signs and
symptom
s of their
illness,
what to
expect
with a
test or
surgery,
and
 expected
outcome
s allows
them to
feel more
in control
of their
care
without
the
unnecess
ary stress
of the
unknown
.

5. This
promote
s
communi
cation
and
support.

6. This
helps the
caregiver
gain
control
over the
situation.

7. Groups
that
come
together
for
 mutual
support
or
informati
on
exchange
can be
beneficia
l in
helping
family
reach
goals.

Subjective Sexual Dysfunction Cerebrovascular STO Independent: Independent: STO

cues: related to neurological diseases are the third After 1 week of
• Assess -Individuals are After 1 week of
damage secondary to leading cause of death nursing
“Paralyzed stroke and one of the major interventions, knowledge of often ignorant of nursing
diton it aada causes of long-term the client will client/SO regarding anatomy of interventions, the
ha ubos iya disability in western be able to: sexual anatomy and sexual system client was not able
lawas labi na countries. Despite this - function and effects of and how it to:
it right side. high prevalence, little Verbaliz current situation or works, impacting
condition. client’s -Verbalize
Dumiri gihap information is available e understanding
understanding of understanding of
ak magpa on sexual functioning of individual
situation and individual reasons
butang and sexual satisfaction reasons for
expectations. for sexual
catheter,” as in stroke patients. In sexual
cases with lesions in the problems. problems.
verbalized by • Assess -Alternative
right cerebellum and the - Identify
the wife. individual needs, methods need to -Identify stressors
left basal ganglia, a stressors in
significant ejaculation lifestyle that desires, and abilities be designed for in lifestyle that may
disorder and decrease of may contribute of client and partner. the individual contribute to the
sexual desire were more to the situation to fulfill dysfunction.
likely to occur, dysfunction. the need for
Objective intimacy and -Identify satisfying
respectively. The most - Identify
cues: common sexual satisfying and closeness and acceptable
problems that have been acceptable • Provide for or sexual practices
- Percei identify ways to -to allow for
identified after stroke sexual practices and alternative
ved obtain privacy. sexual expression
include decline in libido and alternative ways of dealing
limitations for individual
imposed by and coital frequency, ways of dealing and/or between with sexual
disease decline in vaginal with sexual partners without expression.
lubrication and orgasm expression. embarrassment
- right in women, and poor or - Discuss -Discuss concerns
and/or
sided body failed erection and concerns about about body image,
objections of
weakness ejaculation in men body image, sex sex role,
others.
role, desirability desirability as a
- Ruptur as a sexual -Nurse needs to sexual partner with
e of the blood Source: Korpelainen, et. partner with • Encourage become partner/SO.
vessels at the al., (1999). Sexual partner/SO. ongoing dialogue and comfortable with
basal ganglia talking about GOALS NOT MET
Functioning Among take advantage of
– 70 cc bleed Stroke Patients and LTO teachable sexual issue so
on left MCA Their Spouses. After a month he or she can
https://doi.org/10.1161/0 of nursing moments that occur. recognize these LTO
1. interventions, moments and be After a month of
STR.30.4.715 the client will willing to discuss nursing
be able to the client’s interventions, the
regain sexual concerns
client was able to
function
-Partner may regain sexual
need information function
• Provide time and/or
to listen to and discuss counseling about
concerns of partner. alternatives for GOALS MET
sexual activity
and ways to deal
with problems,
such as
impotence or
sexual
aggression.

-When client is
• Assist unable to
client/SO to problem- perform in usual
solve alternative ways manner, there
of sexual expression. are many ways
the couple can
 learn to satisfy
sexual needs.
Dependent:
-May require
• Refer to sex
additional
counselor or therapist
assistance for
and family therapy
resolution of
when indicated.
problems.

Subjective: Impaired Swallowing Dysphagic symptoms STO: After 3 Independent: Independent: STO: After 3 days of
related to stroke as can occur if a stroke days of nursing nursing
“Diri na ito evidenced by decreased affects the brain stem, interventions, 1.Review individual 1.Assess the
interventions, the
hiya strength of muscles such as with lacunar the client will pathology and ability patient’s ability
client was not able
nakakakaon involved in mastication infarcts of the brain stem be able to: to swallow, noting the to swallow as
to:
katungod nga or a hemorrhage in this -Demonstrate extent of the soon as possible
diri man hiya region. Any neurologic feeding paralysis: clarity of and before any ● Demonstra
nakakatulon.” or muscular damage methods speech, tongue oral intake. te feeding
as verbalized along the deglutitive appropriate to involvement, ability to Nutritional methods
by wife. axes can cause individual protect the airway, interventions and appropriate
dysphagia. Thus, central situation with episodes of coughing, choices of to
causes of dysphagia in aspiration presence of feeding routes individual
stroke patients include prevented. adventitious breath are determined situation
Objective:
damage to the cortex or Maintain sounds. Weigh by these factors. with
-Dysphagia brain stem, and desired body periodically as aspiration
peripheral causes weight. indicated. prevented
-Excessive include damage to the
drooling nerves or muscles ● Maintain
involved in swallowing. 2.Timely desired
2.Have suction
Swallowing intervention may body
equipment available
abnormalities can limit the weight
at the bedside.
develop when these untoward effects
damages result in 3.Assist patient with of aspiration. GOAL NOT MET
malfunction, head control and
discoordinated function, 3.Counteracts
position based on
or lack of function of the hyperextension,
specific dysfunction.
neuromuscular aiding in the
apparatus. 4.Place the patient in prevention of
an upright position aspiration and
during and after enhancing the
feeding as ability to
appropriate. swallow. Optimal
positioning can
5.Provide oral care
facilitate intake
based on individual
and reduce the
needs.
risk of aspiration
6.Stimulate lips to head back for
close or manually decreased
open mouth by light posterior
pressure on lips or propulsion of
under the chin if tongue, head
needed. turned to weak
side for unilateral
7.Place food of pharyngeal
appropriate paralysis, lying
consistency on the down on either
unaffected side of the side for reduced
mouth. pharyngeal
8.Touch parts of the contraction.
cheek with a tongue 4.To reduce the
blade and apply ice to risk of aspiration
the weak tongue. by use of gravity
to facilitate
swallowing. Have
the patient sit
upright and tuck
the chin towards
Collaborative: the chest as they
swallow.
1. Administer
intravenous fluids, 5.Patients with
parenteral nutrition, dry mouth
or tube feedings as require
appropriate. moisturizing
agents like
2.Coordinate
alcohol-free
multidisciplinary
mouthwashes
approach to develop a
treatment plan that before and after
meets individual eating. Patients
needs. with excessive
saliva will benefit
from the use of
drying agents
before meals and
moisturizing
agents
afterward.

6.Aids in sensory
retraining and
promotes
muscular control.

7.Provides
sensory
stimulation
(including taste),
increasing
salivation and
triggering
swallowing
efforts.

8.It can improve

tongue
movement and
control
(necessary for
swallowing) and
inhibits tongue
protrusion.
 Collaborative:

1.It may be
necessary for
fluid replacement
and nutrition if
the patient is
unable to take
anything orally.

2.The inclusion of
dietitians, speech
and occupational
therapists can
increase the
effectiveness of
the long-term
plans and
significantly
reduce the risk of
silent aspiration.

UBJECTIVE: Disturbed Sensory Sensory impairments STO: After a Independent Independent STO: After a week
Perception related to significantly limit the week of nursing of nursing
“Tikang hiya neurological trauma ability to use the upper intervention, the 1.Review pathology of 1.Awareness of
intervention, the
nastroke an limb after stroke. client will be individual condition type and area of
client was not able
tuo nga parte Decreased cerebral able to: involvement aids
2.Observe behavioral to:
han iya lawas oxidative metabolism •Acknowledge in assessing
responses such as
kay dire na can cause the abnormal changes in • Acknowledge
hostility, crying, for and
gud naabat release of ability and changes in ability
anticipating
hin sakit o neurotransmitters presence of inappropriate affect, and presence of
specific deficits
nakikiwa leading to cerebral residual agitation, and residual
and planning
naman la” as dysfunction. The cellular involvement. hallucination by using involvement.
care.
verbalized by signaling hypothesis
Los Ranchos (or •Demonstrate
speculates that •Demonstrate
the wife. similar) stroke scale, behaviors to
intraneuronal signal behaviors to
transduction is affected, compensate for as appropriate. 2.Individual compensate for or
causing a change in the or overcome responses are overcome deficits.
Eliminate extraneous
OBJECTIVE neurotransmitter deficits. variable, but
noise and stimuli as LTO: After 3
S production and release LTO: After 3 necessary. commonalities, months of nursing
leading to altered months of such as intervention, the
•Impaired sensation. Any alteration nursing client was not able
verbal in a patient’s normal intervention, the emotional
3.Speak in calm, quiet to:
communicatio environment can result client will be lability, lowered
voice, using short
n in stress especially if able to: frustration •Regain and
sentences. Maintain
such alteration is •Regain and threshold, maintain usual LOC
•Change in eye contact.
involuntary. Sensory maintain usual apathy, and and perceptual
usual overload occurs when an LOC and functioning
response to impulsiveness,
individual experiences a perceptual may complicate
stimuli GOAL NOT MET
stimulus that they are functioning.
care. Use of a
unable to manage and 4.Ascertain and
•Motor stroke scale aids
process. validate client’s
incoordinatio
perceptions. Reorient in documenting
n
client frequently to progress during
environment, staff, initial weeks
and procedures. following insult.

5.Evaluate for visual 3.Reduces

deficits. Note loss of anxiety and
visual field, changes In exaggerated
depth perception emotional
(horizontal or vertical responses and
planes), and presence
confusion
of diplopia.
associated with
6.Approach client sensory overload.
from visually intact
4.Client may
side.
have limited
7.Leave light on; attention span or
position objects to problems with
take advantage of
comprehension.
intact visual fields.
These measures
Patch affected eye or
can help client
encourage wearing of
attend to
prism glasses if
indicated. communication.

5.Assists client to
identify
Collaborative:
inconsistencies in
1.Refer to physical, reception and
occupational, speech, integration of
and cognitive stimuli and may
therapists. reduce
perceptual
distortion of

reality.

6.Presence of
visual disorders
can negatively
affect client’s
ability to
perceive
environment and
relearn motor
skills and
increases risk of
accident and
injury.

7.Provides for
recognition of
the presence of
persons or
objects; may help
with depth
perception
problems; and
prevents client
from being
startled. Patching
may decrease the
 sensory
confusion of
double vision,
and prism glasses
may enhance
vision across
midline,
decreasing
neglect of
affected side.

Collaborative:

1.Interdisciplinar
y approach can
create an
integrated
treatment plan
based on the
individual’s
unique
combination of
abilities and
disabilities with
focus on
evaluation and
functional
improvement in
physical,
cognitive, and
perceptual skills.

Subjective: Acute Pain related to Post-stroke pain is After 24 hours Independent: Independent: After all the nursing
hemiplagia common and can affect of nursing interventions, the
“Nanluluya the rehabilitation and interventions, 1. Assess the patient 1. Hemiplegic
client was not able
ngan quality of life of stroke the client will: for shoulder stiffness, shoulder pain
to:
nagsisinakit it survivors. In a study, pain. (HSP) is a
iya tuo nga patients report newly 1.manifest common and 1.manifeste
2. Assist the patient
parte hit iya developed pain six decrease in pain distressing
lawas.” As months after stroke. when changing complication decrease in pain
verbalized by Causes of HSP are often 2.demonstrate position. related to stroke
the wife. multifactorial and can be stable vital and occurs in the
broadly classified into signs paralytic side of 2. demonstrate
neurological (paralysis, 3. Position the the patient. stable vital signs
spasticity, altered 3.perform shoulder of the Incidence of this
Objective:
sensation and activities for patient appropriately. complication
Narrowed neuropathic pain) and recovery and varies from 12% 3.perform activities
focus mechanical factors rehabilitation to 58% and the for recovery and
(shoulder subluxation, most common
Moaning 4. When lifting the rehabilitation
soft tissue injuries such period of
arm, it should be
as rotator cuff tears, occurrence is at GOAL NOT MET
Increased moved slowly and be
bicipital tendonitis, 8-10 weeks
blood muscle imbalance, rotated outward.
pressure: poststroke (Li &
weakness and altered 5. Perform
180/90 Alexander, 2015).
scapula position) therapeutic technique
mmHg (N: Shoulder pain
of range of movement may prevent
120/80 (Hansen et al., 2012). by holding the patients from
mmHg) humerus under the learning new
Increased axilla and maintaining skills and affect
heart rate 127 external rotation. their
bpm (N: 60- 7. Assist the patient in rehabilitation
100 bpm) performing range-of- and quality of life
motion exercises. poststroke.
Muscle
spasticity 8. Perform soft tissue
massage. 2. Never lift the
Muscle
contractures Collaborative: patient by the
flaccid shoulder
1. Discuss use of or pull on the
alternative or affected arm or
complementary shoulder as this
therapies, such as will cause pain.
acupuncture to the Using an
patient and significant appropriate force
other. when turning or
changing the
patient’s position
will prevent it
from
overstretching
the affected
shoulder joint.
Strenuous arm
and shoulder
movement
should also be
avoided.

3. Many shoulder
problems can be
prevented by
proper patient
movement and
positioning. The
position of the
shoulder should
be checked when
the patient is
assisted in
moving in bed,
and it should be
ensured that the
scapula glides
forward,
particularly when
lying on the
hemiplegic side
(Li & Alexander,
2015). See
interventions for
Impaired Physical
Mobility in this
nursing care
plan.

4. Avoid
impingement. If
the arm is
paralyzed,
incomplete
dislocation
(subluxation) at
the shoulder can
occur due to
overstretching of
the joint capsule
and musculature
by the force of
gravity when the
patient sits or
stands in the
early stages after
a stroke. Elevate
the arm and
hand to prevent
dependent
edema.

5. Lifting the
hemiplegic arm
by holding the
humerus under
the axilla and
maintaining
external rotation
produces a
greater range of
flexion at the
hemiplegic
shoulder than a
distal hold (Tyson
& Chissim, 2002).
Incorrect
handling of
patients can
cause improper
dynamic motor
control and
rotator cuff
tearing.

7. ROM exercises
are essential in
preventing
shoulder
stiffness, thus
preventing pain.
Some activities
the patient can
do include:

-
Interlacin
g the fingers,
place the palms
together, and
push the clasp
hands slowly
forward to bring
the scapulae
forward, then
raise both hands
above the head.

- Flex the
affected wrist at
intervals and
move all joints of
the affected
fingers.

- Push the
heel of the hand
firmly down on a
flat surface.

8. Slow-stroke
back massage
was found to be
effective nursing
intervention for
reducing the
patients’ level of
shoulder pain
perception

Collaborative:

1. May provide
reduction or
relief of pain
without drug-
related side
effects.