IM CASE STUDY 04

Presented by Group 1: BSN 3 – A6

Allawan, Roselyn Joy A.
Alonso, Aprilyn D.
Arcenas, Daniel Christopher J.
Artista, Erica Leigh S.
Bacalan, Marc Cayton S.
Balverde, Shaine Marie L.
 ANATOMY,
PHYSIOLOGY &
PATHOPHYSIOLOGY
 DEMENTIA

Dementia is not a specific disease but is rather a general

term for the impaired ability to remember, think, or
make decisions that interferes with doing everyday
activities. Alzheimer’s disease is the most common type
of dementia. Though dementia mostly affects older
adults, it is not a part of normal aging. Dementia is a
brain disorder that seriously affects a person’s ability to
carry out daily activities. It usually begins after age 60
and the risk goes up as you get older.
 RISK FACTORS OF DEMENTIA
• Age - the strongest known risk factor for dementia is increasing age, with most cases affecting
those of 65 years and older
• Family History - those who have parents or siblings with dementia are more likely to develop
dementia themselves
• Race/Ethnicity - older African Americans are twice more likely to have dementia than whites.
Hispanics 1.5 times more likely to have dementia than whites
• Poor Heart Health - high blood pressure, high cholesterol, and smoking increase the risk of
dementia if not treated properly
• Traumatic Brain Injury - head injuries can increase the risk of dementia, especially if they are
severe or occur repeatedly
 THE NERVOUS SYSTEM
• The nervous system is the major controlling, regulatory, and communicating system in the body.
It is the center of all mental activity including thought, learning, and memory.
• The various activities of the nervous system can be grouped together as three general,
overlapping functions: sensory, integrative, and motor.
• Neurons are the nerve cells that transmit impulses. Supporting cells are neuroglia.
• The central nervous system consists of the brain and spinal cord. Cranial nerves, spinal nerves,
and ganglia make up the peripheral nervous system.
 THE NERVOUS SYSTEM
• The afferent division of the peripheral nervous system carries impulses to the CNS; the efferent
division carries impulses away from the CNS.
• The spinal cord functions as a conduction pathway and as a reflex center. Sensory impulses
travel to the brain on ascending tracts in the cord. Motor impulses travel on descending tracts.
 CLINICAL MANIFESTATIONS
OF DEMENTIA
COGNITIVE CHANGES
• Memory loss, which is usually noticed by someone else
• Difficulty communicating or finding words
• Difficulty with visual and spatial abilities, such as getting lost while driving
• Difficulty reasoning or problem-solving
• Difficulty handling complex tasks
• Difficulty with planning and organizing
• Difficulty with coordination and motor functions
• Confusion and disorientation
 CLINICAL MANIFESTATIONS
OF DEMENTIA
PSYCHOLOGICAL CHANGES
• Personality Changes
• Depression
• Anxiety
• Inappropriate behavior
• Paranoia
• Agitation
• Hallucinations
 DEFINITION OF DISEASES
Cerebrovascular Disease
• blockage, malformation, or hemorrhage prevents the brain cells from getting enough oxygen,
can result to brain damage
• can develop from a variety of causes, including atherosclerosis, where the arteries become
narrow; thrombosis, or embolic arterial blood clot, which is a blood clot in an artery of the
brain; or cerebral venous thrombosis, which is a blood clot in a vein of the brain

Source: https://www.medicalnewstoday.com/articles/184601
 DEFINITION OF DISEASES
Community-Acquired Pneumonia
• is defined as pneumonia that is acquired outside the hospital
• commonly identified pathogens are Streptococcus pneumoniae, Haemophilus influenza, and
viruses.
• Signs and symptoms are fever, cough, sputum production, pleuritic chest pain, dyspnea,
tachypnea, and tachycardia

Source: https://
www.msdmanuals.com/professional/pulmonary-disorders/pneumonia/community-acquired-pneumoni
a
LABORATORY RESULTS
 INTERPRETATION OF LAB RESULTS
Hematology/Complete Blood Count
• A high white blood cell count may indicate that the immune system is working to destroy an
infection. The elevated levels of WBC is linked to the ongoing infection in the patient’s lungs,
which is CAP (Community Acquired Pneumonia).
• Having a high percentage of neutrophils in your blood is called neutrophilia. This is a sign that
your body has an infection. Neutrophilia can point to a number of underlying conditions and
factors, including: infection, most likely bacterial.
 INTERPRETATION OF LAB RESULTS
Blood Glucose Test (First)
• 52 mg/dL of glucose in blood simply indicated that the patient is hypoglycemic. The normal
value of of glucose in blood is 70-99 mg/dL.

Blood Glucose Test (Second)

• A moderately high level of glucose in blood with 119 mg/dL of signifies prediabetes of the
patient.
IgM and IgG are immunoglobulin’s produced by the immune system to provide protection against
SARS-CoV-2. Anti- SARS-CoV-2 IgM and IgG can be detected in samples from affected patients. The
result indicates that the patient is NEGATIVE for COVID-19 Virus.
Procalcitonin(PCT) is a peptide precursor of the hormone calcitonin, the latter being involved with
calcium homeostasis. It rises once procalcitonin is cleaved by endopeptidase. Therefore, the patient’s
PCT indicates low risk of sepsis.
Interpretation:
The patient’s sodium level is 131
mEq/L. Since the normal values of
sodium is 135-145 mEq/L, patient has
hyponatremia due to sodium
disturbances associated with brain
injury.
Interpretation:
The CT-Scan Report
confirms that the patient
has CVD infarction
(Cerebrovascular Disease)
which is a stroke caused by
interruption or blockage of
blood to flow to the brain.
DRUG STUDIES
NURSING CARE PLANS
FDAR
 DATE SHIFT FOCUS TIME DATA, ACTION, RESPONSE

08/13/21 6:00 A.M. – 2:00 P.M. Receiving Assessment 6:00 A.M. D > Received pt. lying on bed, asleep, unconscious, and afebrile..

A > Nursing rounds done, established rapport, v/s taken and charted, encouraged pt. to
8:00 A.M.
verbalize feelings. V/S are as follows: BP 140/90 mmHg, PR 119 BPM, RR 17 CPM, BT
37.1 °C, O₂ Sat 95%.

D > Upon assessment, vital signs: BP 140/80 mmHg, BT 37.0 °C, PR 112 BPM, RR 15
CPM, O₂ Sat 96% .
Impaired Verbal
9:00 A.M. A > Assessed the patient for aphasia and dysarthria. Encouraged patient to verbalize feelings
Communication
about the impact of fatigue. Assessed patient for signs of depression. Helped patient in
promoting sufficient nutritional intake.

End of Shift 2:00 P.M. R > The patient was able to improve his verbal communication skills by the end of the shift,
as evidenced by spontaneous conversation with his significant other.
DISCHARGE PLANNING
 MEDICATION
• Clopidogrel 75 mg/tab, 1 tab OD PO
• Memantine 10 mg/tab 1⁄2 tab OD PO
• Citicoline 1 gm/tab BID PO x 3 months
• Atorvastatin 40 mg/tab a tab OD HS
• Losartan 50 mg/tab, 1 tab OD PO
• Amlodipine 5mg/tab 1tab PO
 ENVIRONMENT
• Encourage family to maintain proper environmental sanitation
• Instruct family to maintain a safe home free from health hazards such as chemicals, irritants,
and sharp objects
• Maintain a calm and stress-free environment to alleviate anxiety
• Label all room and drawers with pictures. Label often-used object (e.g. hairbrushes and
toothbrushes)
• Provide a safe, non-restrictive environment for the client through proper and adequate lighting
 HYGIENE
• Maintain a good hygiene by taking a bath daily.
• Instruct patient to keep self neat and clean.
• Keep oral hygiene healthy.
• Perform hand washing as much as possible.
• Maintain good grooming by dressing neatly, cutting of long nails, and combing of hair.
 DIET
• Maintain a low fat, low sodium diet.
• Avoid foods that may trigger allergies.
• Minimize the intake of liquors and sodas of any brand.
• Initiate intake of foods rich in iron.
• Avoid foods with high sugar content.
 OUTPATIENT REFERRAL
• Observe for any alleviation of symptom.
• Contact nearest healthcare center for emergency purposes.