OBJECTIVES

General Objective After the discussion of this Case Presentation, the students will be able to deal and care for patients with Cerebro Vascular Accident integrally by applying their knowledge, skills, and positive attitudes based on what they have learned out of the discussion. Specific Objectives

COGNITIVE
1. 2. 3. 4. 5.

To be able to comprehend the pathophysiology of the patients disease. To be able to harness knowledge about the patients condition. To be able to determine the purposes of all the medications being administered to the patient and its actions and mechanism of action. To be able to gather factual information regarding the patient condition. To be able to correlate learned knowledge from the classroom to the clinical area.

PSYCHOMOTOR 1. To be able to perform planned nursing interventions. 2. To be able to set priorities and goals in collaborative with the patient. 3. To be able to obtain a nursing health history, conduct physical assessment, review records, organize and validate data. 4. To be able to realize planned interventions for our patient. 5. To be able to formulate nursing diagnoses and collaborative nursing statements. AFFECTIVE 1. To be able to establish rapport with the patient and folks. 2. To be able to empathize with the patient and folks. 3. To be able to address the spiritual needs of the patient. 4. To be able to know the patient better and encourage verbalization of fear and anxiety. 5. To be able to know the feelings of patient towards his condition.

INTRODUCTION
The only way to keep your health is to eat what you dont want, drink what you dont like, and do what youd rather not. -Mark Twain According to the World Health Organization, 15 million people suffer stroke worldwide each year of these, 5 million die and another 5 million are permanently disabled. High blood pressure contributes to over 12.7 million strokes worldwide. Europe averages approximately 650,000 stroke deaths each year. In developed countries, the incidence of stroke is declining - largely due to efforts to lower blood pressure and reduce smoking. However, the overall rate of stroke remains high due to the aging of the population. In the Philippines, it is the most common with 70% of cases. Hemorrhagic stroke accounts for 30% of cases in the country. It is when the blood vessel bursts. Common causes include uncontrolled hypertension where one detects high blood pressure but is hesitant to go to the doctor to consult; or where a hypertensive patient isnt taking medicine, or medicine is taken in inadequate amounts. Both types are fatal. Its said that if one experiences a stroke or brain attack, you are in what is known as a 30-30-30 situation. Meaning, 30% die, 30% lucky and can go to back to normal, and 30% left with disability. The world as a whole has been facing different constant changes not only in the environment but also in peoples lives. As changes occur, the more people become in need to adopt with these changes, thus, and we expose ourselves to illness that could even lead to unwanted events in our lives.

Case Discussion
Cerebrovascular Accident Also known as stroke, a term used to describe neurologic changes caused by an interruption in the blood supply to a part of the brain. It is the sudden death of some brain cells due to lack of oxygen supply when the blood flow to the brain is impaired by blockage or rupture of an artery to the brain. Two types of stroke 1. Ischemic stroke- is caused by a thrombotic or embolic blockage of blood flow to the brain. 2. Hemorrhagic stroke- occurs when an artery ruptures or leaks.

Risk factors
1) smoking 2) excessive alcohol intake 3) uncontrolled high blood pressure 4) high cholesterol 5) overweight/unhealthy diet 6) illegal drugs/abuse of Rx drugs 7) known or unknown heart problems 8) diabetes 9) known or unknown vascular brain defects - aneurysm, etc. 10)family history of stroke

Prevention
Primary prevention Maintaining an ideal body weight Maintaining safe cholesterol level Smoking cessation Using low-dose estrogen contraceptives only in the absence of the other risk factors Reducing heavy alcohol consumption Illuminating illicit drug use

Secondary prevention

Adequate blood pressure control Care of diabetes mellitus Treatment of cardiovascular disease, transient ischemic attack (TIA), and arterial fibrillation

Diagnostic tests

Non-contrast computed tomography scan Magnetic resonance imaging ECG Carotid duplex scanning

Prevent complications

Bleeding Cerebral edema Blood glucose control Stroke recurrence Aspiration

Nursing management 1. Documents the clients condition and course fully, including deficits, status of other diseases, complications, changes in status, and functional status before stroke. 2. Begin physical activity as soon as the clients medical condition is stable. 3. Assist in managing general health functions throughout all stages of treatment. 4. Prevent complications, including deep vein thrombosis and pulmonary embolism, aspiration, skin breakdown, UTI, falls, spasticity and contractures, shoulder injury and seizures. 5. Prevent recurrent strokes through control of modifiable risk factors, oral anticoagulation, anti-platelet therapy, or surgical intervention. 6. Assess throughout acute and rehabilitation stages. 7. Use reliable standardized instruments for evaluation. 8. Evaluate for formal rehabilitation during the acute stage.

9. Choose an individual or interdisciplinary program based on the clients and familys needs. 10. Choose the local rehabilitation program that best meets the clients and familys needs.

Clinical manifestations Manifested in the book Hemiparesis Aphasia Hemisensory loss Severe occipital or nuchal headaches Vertigo or syncope Epistaxis paresthesia Transient paralysis Visual changes Vomiting Seizures Changes in mental status Fever Changes in ECG Dysarthria Dysphagia Apraxia Horner syndrome Agnosia Behavioral changes Incontinence Manifested by the patient

ANATOMY AND PHYSIOLOGY The Brain Three cavities, called the primary brain vesicles, form during the early embryonic development of the brain. These are the forebrain (prosencephalon), the midbrain (mesencephalon), and the hindbrain (rhombencephalon). During subsequent development, the three primary brain vesicles develop into five secondary brain vesicles. The names of these vesicles and the major adult structures that develop from the vesicles follow: The telencephalon generates the cerebrum (which contains the cerebral cortex, white matter, and basal ganglia). The diencephalon generates the thalamus, hypothalamus, and pineal gland. The mesencephalon generates the midbrain portion of the brain stem. The metencephalon generates the pons portion of the brain stem and the cerebellum. The myelencephalon generates the medulla oblongata portion of the brain stem.

FOUR DIVISIONS OF THE BRAIN:

The cerebrum consists of two cerebral hemispheres connected by a bundle of nerve fibers, the corpus callosum. The largest and most visible part of the brain, the cerebrum, appears as folded ridges and grooves, called convolutions. The following terms are used to describe the convolutions: A gyrus (plural, gyri) is an elevated ridge among the convolutions. A sulcus (plural, sulci) is a shallow groove among the convolutions. A fissure is a deep groove among the convolutions.

The deeper fissures divide the cerebrum into five lobes (most named after bordering skull bones)the frontal lobe, the parietal love, the temporal lobe, the occipital lobe, and the insula. All but the insula are visible from the outside surface of the brain. A cross section of the cerebrum shows three distinct layers of nervous tissue:

The cerebral cortex is a thin outer layer of gray matter. Such activities as speech, evaluation of stimuli, conscious thinking, and control of skeletal muscles occur here. These activities are grouped into motor areas, sensory areas, and association areas.

The cerebral white matter underlies the cerebral cortex. It contains mostly myelinated axons that connect cerebral hemispheres (association fibers), connect gyri within hemispheres (commissural fibers), or connect the cerebrum to the spinal cord (projection fibers). The corpus callosum is a major assemblage of association fibers that forms a nerve tract that connects the two cerebral hemispheres. Basal ganglia (basal nuclei) are several pockets of gray matter located deep inside the cerebral white matter. The major regions in the basal ganglia the caudate nuclei, the putamen, and the globus pallidusare involved in relaying and modifying nerve impulses passing from the cerebral cortex to the spinal cord. Arm swinging while walking, for example, is controlled here.

The diencephalon connects the cerebrum to the brain stem. It consists of the following major regions: The thalamus is a relay station for sensory nerve impulses traveling from the spinal cord to the cerebrum. Some nerve impulses are sorted and grouped here before being transmitted to the cerebrum. Certain sensations, such as pain, pressure, and temperature, are evaluated here also. The epithalamus contains the pineal gland. The pineal gland secretes melatonin, a hormone that helps regulate the biological clock (sleep-wake cycles). The hypothalamus regulates numerous important body activities. It controls the autonomic nervous system and regulates emotion, behavior, hunger, thirst, body temperature, and the biological clock. It also produces two hormones (ADH and oxytocin) and various releasing hormones that control hormone production in the anterior pituitary gland. The following structures are either included or associated with the hypothalamus.

The mammillary bodies relay sensations of smell. The infundibulum connects the pituitary gland to the hypothalamus. The optic chiasma passes between the hypothalamus and the pituitary gland. Here, portions of the optic nerve from each eye cross over to the cerebral hemisphere on the opposite side of the brain.

The brain stem connects the diencephalon to the spinal cord. The brain stem resembles the spinal cord in that both consist of white matter fiber tracts surrounding a core of gray matter. The brain stem consists of the following four regions, all of which provide connections between various parts of the brain and between the brain and the spinal cord.

Prominent structures of the brain stem.

The midbrain is the uppermost part of the brain stem. The pons is the bulging region in the middle of the brain stem. The medulla oblongata (medulla) is the lower portion of the brain stem that merges with the spinal cord at the foramen magnum. The reticular formation consists of small clusters of gray matter interspersed within the white matter of the brain stem and certain regions of the spinal cord, diencephalon, and cerebellum. The reticular activation system (RAS), one component of the reticular formation, is responsible for maintaining wakefulness and alertness and for filtering out unimportant sensory information. Other components of the reticular formation are responsible for maintaining muscle tone and regulating visceral motor muscles. The cerebellum consists of a central region, the vermis, and two winglike lobes, the cerebellar hemispheres. Like that of the cerebrum, the surface of the cerebellum is convoluted, but the gyri, called folia, are parallel and give a pleated appearance. The cerebellum evaluates and coordinates motor movements by comparing actual skeletal movements to the movement that was intended.

The limbic system is a network of neurons that extends over a wide range of areas of the brain. The limbic system imposes an emotional aspect to behaviors, experiences, and memories. Emotions such as pleasure, fear, anger, sorrow, and affection are imparted to events and experiences. The limbic system accomplishes this by a system of fiber tracts (white matter) and gray matter that pervades the diencephalon and encircles the inside border of the cerebrum. The following components are included:

The hippocampus (located in the cerebral hemisphere) The denate gyrus (located in cerebral hemisphere)

The amygdala (amygdaloid body) (an almond-shaped body associated with the caudate nucleus of the basal ganglia) The mammillary bodies (in the hypothalamus) The anterior thalamic nuclei (in the thalamus) The fornix (a bundle of fiber tracts that links components of the limbic system)

VITAL INFORMATION NAME N. F AGE 50 years old SEX MALE RELIGION ROMAN CATHOLIC CIVIL STATUS SINGLE ADDRESS POB. TAKAS, CUARTERO CAPIZ DATE OF BIRTH 01/01/1961 chief complaint DIZZINESS; LEFT SIDED WEAKNESS DIET OTF @ 200cc (10-2-6) FEEDINGS; SOFT DIET WARD ST. JOSEPH WARD DATE & TIME OF ADMISSION 7-11-11 @ 8:00 pm ATTENDING PHYSICIAN DR.J.B; DR. J.A ADMITTNG DIAGNOSIS CVA HISTORY OF THE PRESENT ILLNESS

The day prior to admission patient felt headache and numbness of the body while cleaning their backyard, then he was given Norvasc by his sister. PAST MEDICAL HISTORY By year 2002, N.F was admitted to St. Anthony College Hospital due to having UTI. By year 2008, he was admitted again at St. Anthony College Hospital due to Nephrolithiasis and was given some medications to melt down the forming stones. FAMILY HISTORY By the age of 81 years old his mother died due to Hypertension and by the age of 61 years old his father died due to Cancer of the Liver and Cancer of the esophagus.

BRIEF SOCIAL, CULTURAL AND RELIGIOUS BACKGROUND EDUCATIONAL BACKGROUND

He is a Graduate of Cuartero National High School.

OCCUPATIONAL BACKGROUND

He is unemployed and stays on his sisters house.

RELIGIOUS PRACTICES

He is a Roman Catholic and hears mass every Sunday. Seldom prays the Holy Rosary.

ECONOMIC STATUS

They belong to a middle class family status with an allotment of 50,000 per month (sister).

PHYSICAL ASSESSMENT

General Appearance Asleep lying on bed in moderate high back rest position, wearing the hospital gown with ID band on his right wrist. With O2 @ 2 lpm via nasal cannula, with foley catheter and IVF of PLRS 1L x 40cc per hour decreased to KVO. Hair

With visible white hair Moist and shiny Dry scalp Evenly distributed (+) dandruff

Eyes

Sunken eyeballs Teary eyes and slightly red Pale conjunctiva Pupil size of 2mm with sluggish reaction Opens his eyes due to verbal command

Nose

With O2 @ 2 lpm and NGT No swelling and discharges noted.

Mouth

Dry lips and slightly brownish Dental caries noted Tongue is moist and pinkish in color.

Ears

Parallel to head and shoulder No discharges and redness noted Tip of the ears is lined up with the outer corner of the eyes

Neck

Proportional to the size of the body and head No palpable lymph nodes Edema not noted Same color with the skin

Axilla

Warm axilla with minimal hair No masses and tenderness noted non odorous

Skin

(+) bed sores on his left posterior thigh (+) scar on the right elbow Dry skin with minimal hair Brown complexion

Nails

Untrimmed and dirty (+) scar on the right thumb Capillary refill returns in 4 secs.

Respiratory System

(+) O2 at 2 lpm via nasal cannula. RR ranges from 17 22 breaths per minute.

Cardiovascular system

Pulse Rate ranges from 52 - 91 beats per minute. BP ranges from 100/80 150/100mmHg. CR ranges from 54 - 94 beats per minute.

Gastrointestinal System

(+) bowel sounds Distended abdomen

Urinary System

With diaper and foley catheter. Urine output ranges from 40 150 cc per hour.

Musculoskeletal System

Left sided weakness noted Lying on bed in moderate high back rest position most of the time Can moderately move the right side of his body With weak handgrip

General Appraisal
Speech

Seldom speaks but with slurred speech. Questions are usually answered by the folks. Language

Produces uuuhhhh sound. Hearing

Responds with questions through head movement. Mental Status

Disoriented to time, place and person

VI .

PATTERNS OF FUNCTIONING

Home Breathing Pattern

Hospital RR ranges from 17 - 22 bpm. Positioned on moderate high back rest. With oxygen inhalation via nasal cannula @ 2 liters per minute.

Circulation

Bradycardeic sometimes, CR ranges from 54 - 94 beats per minute. Hypertension noted, BP ranges from 100/80 150/100mmHg. Pulse Rate ranges from 52 - 91 beats per minute.

Sleeping Pattern Usually sleeps at around 8:00 to 9:00 in the evening with 2 pillows. Sleeps on his most comfortable positions (in supine or in side lying position).

Usually wakes up at around 5:00 in the morning. He sleeps most of the time in moderate high back rest position.

Drinking Pattern Drinks 8-10 glasses of water daily. Seldom drinks juices or soft drinks.

He was on NGT feeding for more than a week and has 60 to 100 cc fluid intake per day when the NGT was removed.

Eating Pattern Eats three times a day with snacks and has good appetite.

Given 200 400 cc OTF a day.

Elimination Pattern Urinates depending on how much fluid he intake. Eliminates 3 times a day every after meal.

With diaper and foley catheter in place with urine output ranges from 40 - 150 cc per hour. Havent defecated for a week and was given Lactulose once a day for his constipation. Sleeps most of the time. Suffers from left sided weakness.

Recreation and Exercise Pattern Wakes up early in the morning, and do the household chores. Watches television and listens to radio.

Hygiene Pattern He takes a bath once a day (every after household chores)

Practices oral hygiene. TSB done once or twice a day. Gargles with Bactidol. Diapers were changed if contaminated with feces or urine.

DRUG TABULATION Generic Name Pizotifen Hydrogen maleate Brand Name Mosegor Vita Drug class Appetite Enhancers Dosage 10 ml. OD with evening feeding Indications Underweight due to lack of appetite associated with vitamin B. deficiency secondary to impaired dietary intake or absorption; nervous disorders in puberty (anorexia nervosa) old age when prevention of deficiency of B group vitamin is indicated. Contraindications

Overweight; hypervitaminosis Adverse reaction Sedation; Rarely dizziness, dry mouth, constipation, Nervousness in children. Mechanism of Action Inhibits reflux of calcium ion across cell membranes to produce relaxation of coronary vascular smooth muscle to decrease peripheral vascular resistance of smooth muscle (decrease blood pressure) and increase myocardial oxygen delivery in patients with vasosgastic angina. Nursing Responsibilities

May be taken with meals to reduce GI discomfort.

Brand Name Duphalac Generic Name Lactulose Drug class Laxative Dosage 30 cc @ H.S OD Indications Treatment for constipation Contraindications

Low galactulose diet Use cautiously in patients with Diabetes Mellitus.

Adverse reaction Abdominal cramps, Diarrhea, belching, flatulence, gaseous distension, nausea and vomiting. Mechanism of Action Produces an osmotic effect in colon; resulting distention promotes peristalsis. Also decreases ammonia, probably as a result of bacterial degradation, which lowers the pH of colon contents. Nursing Responsibilities

To minimize sweet taste, dilute with water or fruit juice or give with food. Monitor sodium level for hypernatremia, especially when giving in higher doses to treat hepatic encephalopathy. Monitor mental status and potassium levels when giving to patients with hepatic encephalopathy. Replace fluid loss. Dont confuse Lactulose with Lactose.

Generic Name Ranitidine hydrochloride Drug class Histamine H2 receptor blocking drug Dosage 50 mg IV every 8 hours Indications Gastric Ulcer Contraindications Cirrhosis of the liver, impaired renal or hepatic function Adverse reaction Headache, abdominal pain, constipation, diarrhea, nausea and vomiting Mechanism of Action Competitively inhibits gastric acid secretion by blocking the effect of histamine H2 receptors. Both daytime and nocturnal basal gastric acid secretion, as well as food-and penetagastrin-stimulated gastric acid are inhibited. Weak inhibitor of cytochrome P-45 (drug-matabolizing enzymes); thus, drug interactions involving inhibition of hepatic metabolism are not expected to occur Nursing Responsibilities

Visually inspect parenteral drug product for particulate matter, and discoloration before administration. Monitor CBC, B12, RENAL, LFTs. Asses for infections. Teach client to avoid alcohol, aspirin-containing products, and beverages that contain caffeine (tea, cola, coffee); these increase stomach acid. Tell client not to smoke; interferes with healing and drugs effectiveness

Generic Name Losartan Brand Name Lifezar Drug class Angiotensin II antagonists; Antihypetensive Dosage 100 mg tab OD @ 8:00 pm Indications Treatment of HPN alone or in combination with other hypertensives. Contraindications

Contraindicated with patient hypersensitive to Losrtan. Use cautiously with hepatic or renal impairment

Adverse reaction Hypotension, headache, dizziness, insomnia, rashes, diarrhea, abdominal pain, nausea, constipation, dry mouth Mechanism of Action Selectively locks the binding of angiotensin II to specific tissue receptors founf in the vasculars smooth muscle and adrenal gland; this action blocks the vaso constriction effect of rennin-angiotensin system as well as the release of aldosteron leading to decrease BP. Nursing Responsibilities

Administer without regard to meals Monitor patient closely in any situation that may lead to decrease BP secondary to reduction in fluid volume Be alert for adverse reactions and drug interactions

Brand Name Nimodipine Generic Name Nimotopp Drug class

Neurotonics & Nootropics Dosage 30 mg 2 caps TID via NGT Indications Treatment of impaired brain function in old age with pronounced symptoms e.g. impaired memory, impaired drive and mood labiality, prophylaxis, and ischemic neurological deficits due to cerebral vasospasms after subarachnoid hemorrhage. Contraindications

Severe BP lowering GI disturbances In addition for infusion: Deterioration of renal function. Disturbances of heart rhythm Phlebitis Increase of liver enzymes

Adverse reaction GI disturbances, dizziness, headache, marked decreased in BP, sweating, sensation of warmth. Mechanism of Action Inhibits ion calcium influx across cardiac and smooth-muscle cells, decreasing myocardial contractility and oxygen demand; also dilates coronary and cerebral arteries and arterioles. Nursing Responsibilities

Administer before or after meals. Monitor blood pressure and heart rate in all patients, especially at start of therapy Be alert for adverse reactions and drug interaction

Brand Name Dilantin Generic Name Phenytoin Drug class Anticonvulsants

Dosage 200 mg cap via NGT TID Indications Control of grandma ( tonic-clonic ) and psychomotor seizures. Contraindications History of hypersensitivity to phenytoin or other hydantoins. Adverse reaction GI disturbances; ataxia, slurred speech; diplopia, nstagmus and mental confusion with headache dizziness, gingival hyperplasia, hirsutism, hyperglycemia, osteomalacia. Mechanism of Action Limits seizure activity by stabulizes neuronial membranes of hyperexcitable cells through decrease enflux of sodium during action potential. Enflux of calcium is also decreased. Also delays outward potassium current leading to increase refractory period. Nursing Responsibilities

When administering to patients on nasogastric or other enteral foods, do not administer 2 hours before or after dose. Be consistent throughout therapy in relation to feed times. Swallow it whole.

Brand Name Rizek Generic Name Omeprazole Drug class Proton Pump Inhibitor; Antisecretory Drug Dosage 40 mg 1 cap OD Indications Upper GI bleeding in critically ill patient Contraindications

Contraindicated with hypersensitivity to Omeprazole or its components

Adverse reaction Headache, Dizziness, Insomnia, Anxiety, Diarrhea, Abdominal Pain, Nausea, Vomiting, Constipation, and Dry Mouth. Mechanism of Action

Gastric acid-pump inhibitor: suppresses gastric acid secretion by specific inhibition of the hydrogen-potassium ATPase enzyme system at the secretory surface of the gastric parietal cells: blocks the final step of acid production. Nursing Responsibilities

Administer before or after meals. Caution patient to swallow capsule whole, do not chew or crush them Be alert for adverse reactions and drug interactions

Brand name Tempra forte Generic Name Paracetamol Drug class Analgesics and Antipyretic Dosage 500mg 1 tab Q4 hours PRN for temp. > 37.8 c Indications For mild pain or fever Contraindications

in patients hypersensitive to drug and in those with NSAIDS-induced sensitivity reactions, bleeding disorders. Use cautiously in patients with GI lesions, impaired renal function,hypoprothrombinemia, Vit. K deficiency, and thrombocytopenia.

Adverse reaction

Tinnitus, hearing loss, nausea, GI bleeding, dyspepsia, GI distress, occult bleeding. Rash, bruising, uticaria Prolonged bleeding time, leukopenia

Mechanism of Action Thought to produce analgesia by inhibiting prostaglandin and other substances that sensitize pain receptors. Drug may relieve fever by acting on the hypothalamic heat-

regulating center and may exert its anti-inflammatory effect by inhibiting prostaglandin and other substance. Nursing Responsibilities

Do not exceed the recommended dosage Reduce dosage with hepatic impairment Give drug with food if GI upset occurs. Discontinue drug if hypersensitivity reaction occurs

Brand Name Sodium Chloride (Nacl) Generic Name Sodium Chloride Drug class Chloride and sodium replacement Dosage 1 tab TID Indications Fluid electrolyte replacement in hyponatremia caused by severe electrolyte loss, severe salt depletion or dehydration. Contraindications congestive heart failure, severely impaired renal function, hypernatremia, fluid retention Adverse reaction hypernatremia, hypopotassemia, acidosis. Fluid and solute overload leading to dilution of serum electrolyte level, CHF, overhydration, acute pulmonary edema Mechanism of Action Chemical Effect: Replaces and maintains sodium and chloride levels. Therapeutic Effect: Restores normal sodium and chloride levels. Nursing Responsibilities 1. Monitor electrolytes, ECG, liver and renal function studies b. Note level of consciousness

2. Observe S&S of hypernatremia, flushed skin, elevated temperature, rough dry tongue, and edema 3. Monitor VS and I&O 4. Be alert for adverse reactions and drug unteractions.

Brand Name Mannitol Generic Name Osmitrol Drug class Diuretic Dosage 75 mg Q8 Indications

Test dose for marked oliguria or suspected inadequate kidney function. Oliguria. To prevent oliguria or acute renal impairment. Edema; ascites caused by renal, hepatic, or cardiac failure. To reduce intraocular or intracranial pressure.

Diuresis in drug intoxication. Contraindications

Contraindicated in patients hypersensitive to the drug and any of its component, and in those with anuria, severe pulmonary congestion, frank pulmonary edema, severe heart failure, severe dehydration, metabolic edema, progressive renal disease or dysfunction, or active intracranial bleeding except during craniotomy.

Adverse reaction Headache, confusion, tachycardia, chest pain, blurred vision, rhinitis, thirst, nausea, vomiting, diarrhea, urine retension Mechanism of Action Chemical Effect: Increases osmotic pressure of glomerular filtrate, inhibiting tubular reabsorption of water and electrolytes. This elevates blood osmolality, enhancing water and sodium flow into extracellular fluid.

Therapeutic Effect: Increases water excretion, decreases intracranial or intraocular pressure, prevents or treats kidney dysfunction, and promotes excretion of drug overdosage. Nursing Responsibilities

Monitor v/s and fluid intake and output hourly. Be alert for adverse reaction and drug interactions. Tell patient that he may feel thirsty or have a dry mouth.

Brand Name Zynapse Generic Name Citicoline Drug class Anticonvulsant Dosage Citicoline 1 gm IV Q12 & Citicoline Oral Solution 2 mL TID Indications Cerebrovascular Diseases, accelerates the recovery of consciousness and overcoming motor deficit. Contraindications Hypertonia of the parasympathetic Adverse reaction

Edema if given too rapidly or in excess, thrombophlebitis.

Abscess, local tenderness. Mechanism of Action Citicoline activates the biosynthesis of structural phospholipids in the neuronal membrane, increases cerebral metabolism and increases the level of various neurotransmitters, including acetylcholine and dopamine. Citicoline has shown neuroprotective effects in situations of hypoxia and ischemia.

Nursing Responsibilities

Watch out for hypotensive effects Be alert for adverse reaction and drug interaction.

Brand Name Vasalat Generic Name Amlopdipine besilate Drug class Calcium antagonist Dosage 10 mg 1 tab OD Indications Management of HTN and prophylaxis of angina. Contraindications

Severe hypotension and lactation

Adverse reaction

Headache, edema, dizziness, flushing, palpitations, fatigue, nausea, abdominal pain, somnolence, muscle cramps, pruritus and rash.

Mechanism of Action Citicoline activates the biosynthesis of structural phospholipids in the neuronal membrane, increases cerebral metabolism and increases the level of various neurotransmitters, including acetylcholine and dopamine. Citicoline has shown neuroprotective effects in situations of hypoxia and ischemia. Nursing Responsibilities

Watch out for hypotensive effects Be alert for adverse reaction and drug interaction.

DISCHARGE PLANNING

MEDICATION

Encourage the patient to have a strict compliance with regards to the medication to attain therapeutic effects. Explain to the patient the purpose and side effects of the medications so that he will be aware of its effects. Give adequate instructions to the significant others about the importance of the following medications and dietary regimens so that the patients condition can remain stable as soon as possible. Vasalat 10mg 1tab OD Dilantin 100mg 1tab BID Losartan 100mg 1tab OD Mosegor vita syrup 10mL OD Citicholine Oral Solution TID (to consume) 2ml Omeprazole Rizek 40mg 1tab OD X 1week

EXERCISE

Encourage the patient to ambulate and assume his normal activities as long as he can tolerate. Instruct client to have frequent arm exercise Educate the client on proper body mechanics to enable him to relax, be comfortable and prevent strains. Instruct the client to balance activities with adequate rest periods.

TREATMENT

Educate the client on the importance of drug and money compliance. Discuss to the client the complication of the condition because knowledge about the condition supports learning that will decrease anxiety. Instruct the client to report or ask medical assistance when abnormalities occur. Educate the family on how to demonstrate a correct performance of the treatment.

Home teaching To promote adherence to the therapeutic programs, teach the following:

Increase fluid intake to avoid dehydration with aspiration precaution. Continue small frequent feedings to help in returning appetite. Take a bath regularly or maintain proper hygiene Take enough rest. Environmental sanitation is needed to provide a therapeutic way of curing himself. Teach the family of the patient how to properly clean bed sores. Teach the patient the importance of hand washing to avoid the spread of infection and avoid recurring of the disease.

OUT-PATIENT

Remind the patient that he must come back to the hospital one week after, for the follow-up check-up to confirm if the patients condition is really restored. Also to know if there are complications sited during the check up to know if patients condition have worsen or not. Remind the family of the patient regarding his Rehab schedule 3x a week. Advice the family of the client to report any abnormalities observed to provide immediate medical intervention.

DIET

Instruct the family to continue soft diet and always observe for aspiration

SPIRITUALITY

Encourage client to strengthen his faith with Almighty Father to provide spiritual growth and promote healing. Advice the family to pray the Holy Rosary every night. Advice client never to forget God, to ask for Jesus help and to believe in the healing power of the Holy Spirit to promote peace of mind and promote a pleasant atmosphere with everyone.

ACKNOWLEDGEMENT

We, the group 3 of BSN-3B are deeply thankful to the people who helped and make this case presentation possible. They have been with us from the beginning. They have supported, helped, assisted and made this case study easier. We awe the triumph of this case presentation to them. In all that we do, we at all times thank our dear Almighty God first. We are grateful to him for guiding us through the entire time we are preparing for this case presentation. We thank him for giving us knowledge, skills, and attitude in rendering tender loving care to our patient. To the Dean of the Nursing Department, Sr. Editha A. Bagayaua, D.C, for her neverending support, love, care and concern to the students of St. Anthony College, we profoundly value it. To Mrs. Nadia Bisnar, R.N, our ever supportive, clinical instructor, we are truly grateful for the learning that you gave us during our exposure in the Medical Ward. We appreciated all the things that you have done for us. The giving of medications, being disciplined student nurses, and teaching us to have a concept in presenting our case. We will never forget your unpredictable smile despite of our mistakes. To Mrs. Rubilyn Bulquerin-Sumaylo, R.N, we thank you for sharing your knowledge and experiences to us. For the things we have learned in charting, for teaching us the value of practicality in the clinical setting and for all the jokes and funny memories youve shared with us. We will miss the laughters and bloopers especially receive flying in bed, recopy, the confusing ay nagdugo, ay wala, ay nagdugo, the construction worker in pounding the tablet, the charting of discharged nga daw sa ginpalayas nga ido, the unexpected flood from the water jag in the St. Joseph Ward.. To our groupmates, CHA, JHO, DAN, BEL, GEN, YANG, MAC, MEN, YEE, NAY, MAI, continue the friendship and unity we have established in our journey. Be prepared for the next flight. Lets pack up all our things and get ready to fly to RENDU WARD. To Ms. Maureen Patricio, RN. We hope that you will be patient and understanding to us. Continue to guide and share your knowledge and skill with us. See you at RENDU ward maam! Coming na kami. Hehe J To our parents who supported us financially throughout this case presentation, thank you so much. We cant do anything without our parents. Without their love and patience to us, this case presentation would be impossible. They have spent money, effort and time just to sustain our needs. To Solano Family, who welcomed us in their home for us to have a place to stay wherein we could finish our case presentation. We also would like to thank our adviser, Ms. Jimmellee Ellen Olilang, who guided us all through the way. Youve been a good mother to us. We thank you for having great

patience to us. Thank you for always reminding us never to give up and be strong, to study hard and believe that we can do it. Thank You Maam!