I.

Demographic Data

Client’s Name: Manang

Sex: Female

Age: 71 years old

Birthdate: September 18, 1937

Birthplace: Liliw, Laguna

Status: Married

Nationality: Filipino

Religion: Roman Catholic

Address: Liliw, Laguna

Educational Background: Elementary Graduate

Occupation: None

Hospital: Community General

Hospital

Date of Admission: June 29, 2009

Final diagnosis: CVA, Subarachnoid

Hemorrhage

II. Sources and Reliability of Information

Upon interview and history taking, data were gathered from the

patient’s relatives. All the significant information regarding

laboratory results, diagnostic procedures, medication orders,

1
physical findings, and other pertinent records were acquired from

the patient’s chart. The patient was observed and assessed during

physical assessment to obtain relevant data that is vital in

identifying actual and potential problems.

III. Reason for Seeking Care

Manang was brought to Community General Hospital on June 29,

2009 at 8:00 pm after being referred to by Nagcarlan Hospital. She

was found unconscious by her granddaughter at 5:30 pm. She was

immediately rushed to the hospital by her son and nephew.

IV. History of Present Illness

Three hours prior to admission, Manang had been feeling dizzy while

she was watching television. This dizziness eventually progressed to

loss of consciousness.

V. Past Medical History

According to the relatives, Manang has had hypertension since she

was 40 years old. She has been taking her maintenance medications

religiously until a month ago when they noticed that she was

purposely skipping taking them. The relatives could not recall what

her meds are. They also said that it was the second time the patient

experienced stroke. The first time was in 2001 while she was in

ballroom dancing.

2
VI. Family History

Patient’s Paternal Patient’s Paternal Patient’s Maternal Patient’s Maternal

Grandpa; Grandma; Grandpa; Grandma;
unrecalled- unrecalled- unrecalled- unrecalled-
deceased deceased deceased deceased

Patient’sFather Patient’sMother
deceased deceased

Patient’s Patient Brother

husband Manang Deceased at age 67
71 y/o 71 y/o (HPN, DM,,renal disorder)

Legend:

Patient: CVA HEMORRHAGIC (Subarachnoid) Female:

Deceased

3
 Male: Deceased Male: Hypertensive

According to the family history, Manang’s parents are both

deceased including her grandparents from both sides due to reasons

unrecalled by her relatives. She has one younger brother who died

at the age of 67 a month before her hospitalization because of

complications brought about by diabetes. Manang’s husband is

hypertensive also. The family history shows hypertension in the

family since she and her brother got it.

VII. Functional Assessment

A. Health Perception and Maintenance

Manang regularly visited hospital for check-ups. As mentioned, she

sticks to her pharmacologic regimen in order to take good care of

her health. But when her brother passed away a month ago, she

started to skip her medications and became stressed.

B. Activities/ Exercise Pattern

Manang does not engage into a regular exercise. But her relatives

mentioned that she does household chores because she could not

stand dirty things. These chores made her busy at home and serve

as her own exercise. They said that she doesn’t stop until all the

furniture’s and dishes are clean.

C. Sleep/ Rest Period

When asked about her sleeping pattern, the relatives said that she’s

not getting enough sleep. She only has about three hours of sleep a

4
day. Because of being awake even late at the night, she tried to find

time to rest at daytime. She managed to take a nap.

D. Nutrition and Elimination

Manang is fond of eating vegetables, fruits, and meat. Her relatives

told us that she loves coffee. According to her relatives, her bowel

movement is not regular. She did it once in three days before she

was hospitalized.

E. Interpersonal Relationship

The life of Manang centers on her husband and six off springs (all of

them has their own family). Her relatives mentioned they regularly

visit Manang to keep her company because she completely dotes on

her grandchildren. They also shared with us that Manang has a good

relationship with the neighbors.

F. Sexuality and Reproductive

Manang is already on her menopausal years. According to the

relatives, she and her husband get along pretty well. According to

Erik Erikson’s theory, she’s now on her “Integrity versus despair”

stage.

G. Coping and Stress Management/ Tolerance Pattern

Manang has an unwavering faith in the Lord and she attended mass

regularly with her husband. Whenever problems come their way,

5
she just prayed and believed everything will be okay for as long as

God is with you. She and her family stay together to solve whatever

hardships arise. But lately, things are not getting too smooth for

Manang. Her relatives stressed that Manang considered the death of

her brother a blow to her for she is very fond and close to him. Even

if they tried to cheer her up, the loneliness stayed with her.

H. Personal Habits

Manang stayed at home and spent her leisure watching television.

She used to engage in ballroom dancing but since her first stroke in

2001, she stopped doing this and just concentrated on making their

home clean. When she gets bored, she sometimes goes to one of

her neighbors to chat.

I. Environmental Hazards

The house of Manang is near the highway where all forms of

transportation pass. Her relatives say that the noise coming from

the vehicles are loud but it’s bearable. They mentioned that when it

rains heavily, it does not flood in their area.

VIII. Review of Systems

System 1st day 2nd day

July 9, 2009 July 10, 2009
General Appearance • Expressive • Expressive
aphasia aphasia
• Conscious • Conscious
• Afebrile • Afebrile
• With protruded • With protruded
tongue tongue
• Capillary refill • Poor eye

6
 of 2 – 3 seconds contact
• Poor eye • Psychomotor
contact decreased
• Psychomotor • Pale nail bed
decreased • Impaired and
• Pale nail bed limited
• Soft palate fails coordination by
to rise in weakness
paralysis on • Decreased
cranial nerve X muscle strength
• Impaired and • Uses
limited incomprehensib
coordination by le sounds
weakness • Noted drooling
• Decreased of saliva
muscle strength
• Uses
incomprehensib
le sounds
• noted drooling
of saliva
HEENT • Slight loss of • Slight loss of
hearing hearing
• With hair • With hair
thinning thinning
• With NGT @ the • With NGT @ the
right nostril right nostril
• Pupil • Anicteric sclera
2mm,sluggishly • Pink palpebral
reactive to light conjunctiva
• Anicteric sclera
• Pink palpebral
conjunctiva
Cardiovascular • BP 130/80 • BP 130/80
mmhg mmhg
• PR 68 bpm • PR 82 bpm
• With full equal
pulses
Integumentary • Slightly flaky • Slightly flaky
skin skin
• Pale in • Pale in
appearance appearance
• Slightly dry lips • Slightly dry lips
• Pale nail bed • Pale nail bed
Gastro intestinal • Flabby • Flabby
tract abdomen abdomen

7
 • No bowel • No bowel
movement movement
• With NGT at • With NGT at
right nostril right nostril

Genitourinary • Urine output • Urine output

950 cc 690 cc
• Menopause • Menopause
Respiratory • RR= 19 cpm • RR= 23 cpm
• with crackles at • with crackles at
both lung fields both lung fields
Central nervous GLASCOW COMA GLASCOW COMA
system scale: scale:
• Eye opening = • Eye opening =
to speech 3 to speech 3
• Verbal response • Verbal response
= =
incomprehensib incomprehensib
le 2 le 2
• motor response • motor response
= flexion 3 = flexion 3
(decorticate) (decorticate)
• Total GCS = 8 • Total GCS = 8
awake and awake and
disoriented disoriented
• With limitation • With limitation
on movement on movement
Neurologic Grading reflexes: Grading reflexes:
• Plantar flexor + • Plantar flexor +
1 diminished, 1 diminished,
low normal low normal
• Babinski +1 • Babinski +1
diminished low diminished low
Normal Normal
Sensory: Sensory:
• Cranial nerve 1 • Cranial nerve 1
able to smell able to smell
but unable to but unable to
verbalized what verbalized what
she smell she smell
Motor: Motor:
• Cranial nerve 3 • Cranial nerve 3
pupil 2 mm, pupil 2 mm,
sluggishly sluggishly
reactive to light reactive to light
Both: Both:
• Cranial nerve 5 • Cranial nerve 5

8
 respond to respond to
touch but touch but
unable to unable to
swallow swallow
• cranial nerve 7 • cranial nerve 7
can elevate can elevate
eyebrows eyebrows
Musculoskeletal Muscle strength Muscle strength
• RU = 1/5 LU = • RU = 1/5 LU =
4/5 4/5
• RL = 3/5 LL = • RL = 3/5 LL =
4/5 4/5
• With limitation • With limitation
on movement on movement
• Psychomotor • Psychomotor
decreased decreased
• Decreased • Decreased
muscle strength muscle strength

IX. Anatomy and Physiology

Anatomy and Physiology

Human Brain

The brain consists of 10-10 neurons that are very closely

interconnected via axons and dendrites. The neurons themselves
are vastly outnumbered by glial cells. One neuron may receive
stimuli through synapses from as many as 10 to 10 other neurons
(Nunez, 1981). Embryologically the brain is formed when the front
end of the central neural system has folded. The brain consists of
five main parts, as described in Figure 5.5:

1. The cerebrum, including the two cerebral hemispheres

2. The interbrain (diencephalon)
3. The midbrain
4. The pons Varolii and cerebellum
5. The medulla oblongata

9
 Fig. 5.5. The anatomy of the brain.

The entire human brain weighs about 1500 g (Williams and

Warwick, 1989). In the brain the cerebrum is the largest part. The
surface of the cerebrum is strongly folded. These folds are divided
into two hemispheres which are separated by a deep fissure and
connected by the corpus callosum. Existing within the brain are
three ventricles containing cerebrospinal fluid. The hemispheres are
divided into the following lobes: lobus frontalis, lobus parietalis,
lobus occipitalis, and lobus temporalis. The surface area of the
cerebrum is about 1600 cm², and its thickness is 3 mm. Six layers,
or laminae, each consisting of different neuronal types and
populations, can be observed in this surface layer. The higher
cerebral functions, accurate sensations, and the voluntary motor
control of muscles are located in this region.

The interbrain or diencephalon is surrounded by the cerebrum

and is located around the third ventricle. It includes the thalamus,
which is a bridge connecting the sensory paths. The hypothalamus,
which is located in the lower part of the interbrain, is important for
the regulation of autonomic (involuntary) functions. Together with
the hypophysis, it regulates hormonal secretions. The midbrain is a
small part of the brain. The pons Varolii is an interconnection of
neural tracts; the cerebellum controls fine movement. The medulla
oblongata resembles the spinal cord to which it is immediately
connected. Many reflex centers, such as the vasomotor center and
the breathing center, are located in the medulla oblongata.
In the cerebral cortex one may locate many different areas of
specialized brain function (Penfield and Rasmussen, 1950; Kiloh,
McComas, and Osselton, 1981). The higher brain functions occur in
the frontal lobe, the visual center is located in the occipital lobe, and
10
the sensory area and motor area are located on both sides of the
central fissure. There are specific areas in the sensory and motor
cortex whose elements correspond to certain parts of the body. The
size of each such area is proportional to the required accuracy of
sensory or motor control. These regions are described in Figure 5.6.
Typically, the sensory areas represented by the lips and the hands
are large, and the areas represented by the midbody and eyes are
small. The visual center is located in a different part of the brain.
The motor area, the area represented by the hands and the
speaking organs, is large.

Fig. 5.6. The division of sensory (left) and motor (right)

functions in the cerebral cortex. (From Penfield and
Rasmussen, 1950.)

Brain Function

Most of the information from the sensory organs is communicated

through the spinal cord to the brain. There are special tracts in both
spinal cord and brain for various modalities. For example, touch
receptors in the trunk synapse with interneurons in the dorsal horn
of the spinal cord. These interneurons (sometimes referred to as
second sensory neurons) then usually cross to the other side of the
spinal cord and ascend the white matter of the cord to the brain in
the lateral spinothalamic tract. In the brain they synapse again with
a second group of interneurons (or third sensory neuron) in the
thalamus. The third sensory neurons connect to higher centers in
the cerebral cortex.
In the area of vision, afferent fibers from the photoreceptors
carry signals to the brain stem through the optic nerve and optic

11
tract to synapse in the lateral geniculate body (a part of the
thalamus). From here axons pass to the occipital lobe of the cerebral
cortex. In addition, branches of the axons of the optic tract synapse
with neurons in the zone between thalamus and midbrain which is
the pretectal nucleus and superior colliculus. These, in turn, synapse
with preganglionic parasympathetic neurons whose axons follow the
oculomotor nerve to the ciliary ganglion (located just behind the
eyeball). The reflex loop is closed by postganglionic fibers which
pass along ciliary nerves to the iris muscles (controlling pupil
aperture) and to muscles controlling the lens curvature (adjusting its
refractive or focusing qualities). Other reflexes concerned with head
and/or eye movements may also be initiated.
Motor signals to muscles of the trunk and periphery from
higher motor centers of the cerebral cortex first travel along upper
motor neurons to the medulla oblongata. From here most of the
axons of the upper motor neurons cross to the other side of the
central nervous system and descend the spinal cord in the lateral
corticospinal tract; the remainder travel down the cord in the
anterior corticospinal tract. The upper motor neurons eventually
synapse with lower motor neurons in the ventral horn of the spinal
cord; the lower motor neurons complete the path to the target
muscles. Most reflex motor movements involve complex neural
integration and coordinate signals to the muscles involved in order
to achieve a smooth performance.
Effective integration of sensory information requires that this
information be collected at a single center. In the cerebral cortex,
one can indeed locate specific areas identified with specific sensory
inputs (Penfield and Rasmussen, 1950; Kiloh, McComas, and
Osselton, 1981). While the afferent signals convey information
regarding stimulus strength, recognition of the modality depends on
pinpointing the anatomical classification of the afferent pathways.
(This can be demonstrated by interchanging the afferent fibers from,
say, auditory and tactile receptors, in which case sound inputs are
perceived as of tactile origin and vice versa.)
The higher brain functions take place in the frontal lobe, the
visual center is in the occipital lobe, the sensory area and motor
area are located on both sides of the central fissure. As described
above, there is an area in the sensory cortex whose elements
correspond to each part of the body. In a similar way, a part of the
brain contains centers for generating command (efferent) signals for
control of the body's musculature. Here, too, one finds projections
from specific cortical areas to specific parts of the body.

Major Blood Vessels

12
Normal function of the brain's control centers is dependent upon
adequate supply of oxygen and nutrients through a dense network
of blood vessels.

Blood is supplied to the brain, face, and scalp via two major sets of
vessels: the right and left common carotid arteries and the right and
left vertebral arteries.

The common carotid arteries have two divisions. The external

carotid arteries supply the face and scalp with blood. The internal
carotid arteries supply blood to the anterior three-fifths of cerebrum,
except for parts of the temporal and occipital lobes. The
vertebrobasilar arteries supply the posterior two-fifths of the
cerebrum, part of the cerebellum, and the brain stem.

Any decrease in the flow of blood through one of the internal carotid
arteries brings about some impairment in the function of the frontal
lobes. This impairment may result in numbness, weakness, or
paralysis on the side of the body opposite to the obstruction of the
artery.

Occlusion of one of the vertebral arteries can cause many serious

consequences, ranging from blindness to paralysis.

Anterior Cerebral Artery

13
The anterior cerebral artery extends upward and forward from the
internal carotid artery. It supplies the frontal lobes, the parts of the
brain that control logical thought, personality, and voluntary
movement, especially the legs. Stroke in the anterior cerebral artery
results in opposite leg weakness. If both anterior cerebral territories
are affected, profound mental symptoms may result (akinetic
mutism).

Middle Cerebral Artery

The middle cerebral artery is the largest branch of the internal

carotid. The artery supplies a portion of the frontal lobe and the
lateral surface of the temporal and parietal lobes, including the
primary motor and sensory areas of the face, throat, hand and arm
and in the dominant hemisphere, the areas for speech. The middle
cerebral artery is the artery most often occluded in stroke.

Posterior Cerebral Artery

14
The posterior cerebral arteries stem in most individuals from the
basilar artery but sometimes originate from the ipsilateral internal
carotid artery [Garcia JH et al., In Barnett HJM at al (eds) Stroke
Pathophysiology, Diagnosis, and Management New York Churchill
Livingstone 1992 125]. The posterior arteries supply the temporal
and occipital lobes of the left cerebral hemisphere and the right
hemisphere. When infarction occurs in the territory of the posterior
cerebral artery, it is usually secondary to embolism from lower
segments of the vertebral basilar system or heart.

Clinical symptoms associated with occlusion of the posterior

cerebral artery, depend on the location of the occlusion and may
include thalamic syndrome, thalamic perforate syndrome, Weber's
syndrome, contralateral hemplegia, hemianopsia and a variety of
other symptoms, including including color blindness, failure to see
to-and-fro movements, verbal dyslexia, and hallucinations. The most
common finding is occipital lobe infarction leading to an opposite
visual field defect.

The posterior cerebral arteries stem in most individuals from the

basilar artery but sometimes originate from the ipsilateral internal
carotid artery [Garcia JH et al., In Barnett HJM at al (eds) Stroke
Pathophysiology, Diagnosis, and Management New York Churchill
Livingstone 1992 125]. The posterior arteries supply the temporal
and occipital lobes of the left cerebral hemisphere and the right
hemisphere. When infarction occurs in the territory of the posterior
cerebral artery, it is usually secondary to embolism from lower
segments of the vertebral basilar system or heart.

Clinical symptoms associated with occlusion of the posterior

cerebral artery, depend on the location of the occlusion and may
include thalamic syndrome, thalamic perforate syndrome, Weber's
syndrome, contralateral hemplegia, hemianopsia and a variety of
other symptoms, including including color blindness, failure to see
to-and-fro movements, verbal dyslexia, and hallucinations. The most
15
common finding is occipital lobe infarction leading to an opposite
visual field defect.

The posterior cerebral arteries stem in most individuals from the

basilar artery but sometimes originate from the ipsilateral internal
carotid artery [Garcia JH et al., In Barnett HJM at al (eds) Stroke
Pathophysiology, Diagnosis, and Management New York Churchill
Livingstone 1992 125]. The posterior arteries supply the temporal
and occipital lobes of the left cerebral hemisphere and the right
hemisphere. When infarction occurs in the territory of the posterior
cerebral artery, it is usually secondary to embolism from lower
segments of the vertebral basilar system or heart.

Clinical symptoms associated with occlusion of the posterior

cerebral artery, depend on the location of the occlusion and may
include thalamic syndrome, thalamic perforate syndrome, Weber's
syndrome, contralateral hemplegia, hemianopsia and a variety of
other symptoms, including including color blindness, failure to see
to-and-fro movements, verbal dyslexia, and hallucinations. The most
common finding is occipital lobe infarction leading to an opposite
visual field defect.

16
 X. Pathophysiology

Precipitating Factors: Predisposing Factors:

>Hypertension >Age
>History of previous >Acute Stress
Stroke >Lifestyle

Overactive of the sympathetic nervous system leading

to increase stress response

Vasoconstriction

Blockage of the blood vessel Embolism

Lack of Oxygen and Nutrients

Supply

Hypoxia

Altered cerebral metabolism

Cytotoxic edema

Aneurysm Rupture

Blood supply to the area supplied by

artery reduced
Sudden entry of
blood into SA space Increase ICP

Brain Tissue Necrosis

• Paralysis, decreased muscle
strength, psychomotor
decreased, Impaired and
limited coordination by
weakness

XI. Laboratory Results

17
Pathology (06-29-09)

Fluid Result Normal Nursing

Range implication
Creatinine .8 mg/dl .7-12
Sodium 140 mmol/L 135-145
Potassium 2.3 mmol/L 3.5 May indicate
deficient dietary
intake, diuretic
administration

Pathology (06-30-09)

Fluid Serum Result Normal Nursing

Range implication
Cholesterol 194 mg/dl 97-201
Triglyceride 71 mg/dl 0-150
s
Direct HDLC increase 85 mg/dl 40-60 Indicates that
increase in
HDLC serves
as protective
role by
mobilizing
cholesterol
from tissues.
Serves as
protection
against
cardiovascula
r diseases.
VLDL 14 mg/dl 0-35
Potassium 4.0 mmol/L 3.5-5-1
LDL 94 mg/dl 0-160
CHOL/dHDL 2.27 mg/dl 0-00-
1000.00

Pathology (07-08-09)

Fluid Serum Result Normal Nursing

Range implication
Sodium Low 134 137-145 may indicate
mmol/L deficient
dietary
intake,
nasogastric

18
 aspiration,
diuretic
administratio
n,
Potassium Low 2.4 mmol/L 3.5-5.1 may indicate
deficient
dietary
intake,
diuretics,

Hematology (07-08-09)

Test Result Normal range Nursing

implication
Hemoglobin 136 120-160 g/L
Hematocrit 0.42 0.37-0.47
WBC 15.7 4-10x10^g/L May indicate
presence of
infection, severe
emotional or
physical stress
Neutrophils .76 0.50-0.70
Lymphocyte .22 0.20-0.40
Eosinophils .02 0.01-0.03
Platelets adequate 0.00-0.01

Chest X-ray (06-29-09)

There is note of suspicious right apical density: suggest apico-

lordotic view. Heart is enlarged with left ventricular prominence.
Aorta is prominent. Tortous and calcified there are lateral marginal
osteophytes noted in the thoracic spine. No other significant chest
x-ray findings.

Impression:

• Suspicious Right Apical Density

• Slight Left Ventricular Prominence

• Atherosclerotic Aorta

• Degenerative Thoracic Osteophytosis

19
Cranial CT-Scan (06-29-09)

Clinical history: LOC; History of Stroke in 2001

Technique: Axial cranial CT slices are obtained without contrast.

The subaranoid spaces are diffusely hyperdense. Well

circumscribed hypodense foci are seen in the normal capsule-
ganglionic region and left copona radiate. Small calcifications are
also noted in the bilateral basal ganglia the gray white matter
interface is maintained. There is no midlife shift.

Hyperdensities seen in the occipital horns of the lateral

ventricles. The basilar and vertebral arteries are calcified. The
visualized posterior fossa, penial region, orbits,

All petromatoins and body calvarium are intact with no

demonstrable fracture seen.

Impression:

• Diffuse subarachnoid hemorrhage with intravenous seepage

and 2nd mild obstructive hydrocephalus

• Old infarcts in the right capsule-ganglionic region and left

corona radiate

• Atherosclerotic basilar and vertebral arteries

• Age r/t bilateral ganglia calcification

Ultrasound of the Abdomen

Pancreas- 1.9 x 1.2 x 1.1 cm

Gall bladder- 6.6 x 2.4

Right kidney- 8.7 x 3.8 x 3.4 CT- 1.3 cm

Left kidney- 8.7 x 3.7 x 3.8 CT- 1.7 cm

Spleen- 5.8 x 3.4 cm

The liver is normal, in size, smooth contour and homogenous

parenchymal echopattern. Both right and left intrahepatic and
extrahepatic bile ducts are not dilated. There are no focal mass or
calcifications seen. Common bile duct measures 3mm.

The gallbladder is not dilated. Wall is not thickened. No

intraluminal mass, echoes or bile sludge formation.

20
 Pancreas and spleen are both normal in size configuration and
echotexture. There are no soiled nor fluid filled masses noted.
Pancreatic duct is not dilated. Splenic vein is not dilated.

Both kidneys are in normal size and orientation with intact

renal margin. Both showed normal and homogenous parenchymal
echogenicity. The cortical thickness is within normal showing distinct
corticomedullary differentiation. There is no evidence of lithiasis,
renal cyst, mass or hydronephrosis bilaterally. The perirenal spaces
are clear. Both central echo-plexes are intact. Ureters are not
dilated.

Urinary baldder is physiologically distended. No intraluminal

calculus or extrinsic mass compression. The uterus is atrophic

Both ovaries are not seen, most likely atrophic. No adnexal

mass seen. No fluid in the posterior cul de sac. Visualized intestinal
bowel loops are normal.
Impression:

• Normal sonogram of liver, gallbladder, biliary tree, pancreas

and spleen

• Normal kidneys, ureters and urinary bladder

• (-) for fluid or mass

• Normal bowel loops

• Atrophic uterus

• Ovaries are not seen, most likely atrophic

• Normal adnexae

21
XII. Drug Study

22
 GENERIC CLASSIFICATION DOSAGE, INDICATIONS/ SIDE EFFECTS MODE OF NURSING
ROUTE, ACTION RESPONSIBILITIES
FREQUENCY CONTRAINDICATIONS

 Central nervous 30 mg CAP q8 Indications: CNS: ataxia, May  Assess blood

system drug decreased stabilize pressure. watch for
GN:Phenytoin  To control tonic-clonic coordination, neural adverse reactions
and complex partial mental confusion, membranes
Stock dose: seizures. slurred speech, and limit  Explain drug therapy,
 Anticonvulsant 30 mg
dizziness, seizure need for follow-up
headache, insomia, activity tests and importance
BN:Dilantin Contraindications: nervousness either by of taking the drug
Date started: increasing exactly as prescribed.
June 29 2009  Contraindicated in efflux or
patients hypersensitive to decreasing  Divided doses given
CV: periarteritis after meals or with
dilantin and those with influx of
nodosa meals may decrease
sinus bradycardia, SA sodium ions
block, second or third AV acrosscell GI reactions.
block, Adam’s stroke membranes
EENT: diplopia,  Don’t stop sudden
syndrome in the
nystagmus, blurred (Doctor’s order)
motor
vision because this may
cortex
worsen seizures. Call
during
 Use cautiously in prescriber immediately
generation
patients with hepatic if adverse reaction
GI: gingival of nerve
dysfunction, hypotension, develop.
hyperplasia,nausea, impulse
myocardial insufficiency
or diabetes vomiting,
constipation
 If using to treat
seizures, take
appropriate safety
SKIN: discoloration precautions.
of the skin if given
via IV push in the
back of hand,
exfoliative  If seizure control is
dermatitis established with
divided doses once
OTHERS: hirsutism dailydosing may be
or considered.
lymphadenopathy 23
24
 GENERIC CLASSIFICATION DOSAGE, INDICATIONS/ SIDE EFFECTS MODE OF NURSING
ROUTE, ACTION RESPONSIBILITIES
FREQUENCY CONTRAINDICATIONS

GN:Nimodipine  Calcium channel 30mg, CAP Indications: CNS: headache Inhibits  Monitor blood
blocker QID calcium ion pressure and heart
 To remove neurologic CV: hypotension, influx rate, especially at start
deficits after a edema across of therapy
BN:Nimotop subarachnoid hemorrhage cardiac and
Stock dose: from ruptured intracranial GI: nausea,
smooth
30 mg berry aneurism abdominal
muscle
discomfort  Monitor weight and
Date started: cells,
decreasing fluid intake and
June 29 2009 MUSCULO-
myocardial output. Stay alert for
Contraindications: SKELETAL:
contractility fluid retention.
muscle cramps
 Adjust a dose and use and oxygen Advise to take drug
cautiously for patients RESPIRATORY: demands; on empty stomach 1
with hepatic failure dyspnea, also dilates hour before 2 hours
wheezing coronary after meal. Instruct
and him not to consume
cerebral grapefruit or grapefruit
arteries and juice within 1 hour 0r 2
arterioles hours after taking the
drug.

25
 GENERIC CLASSIFICATION DOSAGE, INDICATIONS/ SIDE MODE OF NURSING
ROUTE, EFFECTS ACTION RESPONSIBILITIES
FREQUENCY CONTRAINDICATIONS

GN:amlodipine  Cardiovascular 10mg, TAB, Indications: CNS: Inhibits  Alert: monitor patient
besylate system drug OD headache, calcium ion carefully. Some patient,
 Hypertension fatigue, influx across especially those with
dizziness, cardiac and severe obstructive
light- smooth coronary artery
 Anti- hypertensive Stock Dose: 10
 Chronic stable angina, headedness, muscle disease, have
mg
vasospastic angina paresthesia cells, developed increased
(Prinzmetal’s or variant decreasing frequency, duration or
BN: Norvasc myocardial severity of angina or
angina)
Date Started: contractility acute MI after initiation
CV: edema,
and oxygen of calcium channel
June 29 2009 flushing,
demands; blocker therapy or at
palpitations
also dilates time of dosage
coronary increase.
GI: nausea,
and cerebral
abdominal
arteries and
pain
arterioles
 Monitor blood
GU: sexual pressure frequently
difficulties during initiation of
therapy.
MUSCULO_
SKELETAL:  Notify prescriber if
muscle pain signs of heart failure
occur such as swelling

26
 of hands and feet or
RESPI: shortness of breath.
dyspnea

SKIN: rash,
 Don’t confuse
pruritus
amlodipine with
amiloride.

27
 GENERIC CLASSIFICATION DOSAGE, INDICATIONS/ SIDE MODE OF NURSING
ROUTE, EFFECTS ACTION RESPONSIBILITIES
FREQUENCY CONTRAINDICATIONS

Two  Use cautiously for

GN:Lactulose Laxatives 30 ml oral Indications: mechanisms are patients treated with
abdominal lactulose syrup
(syrup) OD believed to be
Relief of constipation discomfort
Stock Dose: including chronic involved in the
BN: Lilac associated
120 ml constipation. Portal laxative action  No laxative should be
systemic encephalopathy: with flatulence
Date started: of lactulose: taken for >1 week
Hepatic coma or precoma and intestinal
June 30 2009 stages where First, without the advice of a
hyperammonemia is cramps.
metabolism of physician. No laxative
present.
Nausea and lactulose by should be used in the

vomiting bacteria results presence of abdominal

Contraindications: in reduced pain nausea, fever or
diarrhea with colonic pH vomiting, as such
potential
which symptoms may signal
Patients who require a low complications
lactose diet; with eg, loss of stimulates appendicitis or an
galactosemia or fluids, peristalsis and inflamed bowel.
disaccharide deficiency; hypokalemia
with intestinal obstruction. and decreases stool
hyponatremia. transit time. In
turn, decreased  Care should be taken
in patients who are
water lactose-intolerant.
reabsorption
from the feces
further  For elderly,
debilitated patients
facilitates the who receive lactulose
passage of soft for >6 months should
have serum
well-formed electrolytes
stools. Second, (potassium, chloride, 28
increased carbon dioxide)
measured periodically.
osmotic
 GENERIC CLASSIFICATION DOSAGE, INDICATIONS/ SIDE MODE OF NURSING
ROUTE, EFFECTS ACTION RESPONSIBILITIES
FREQUENCY CONTRAINDICATIONS

GN: Losartan  Angiotensin II 100mg, TAB, Indications: Abdominal A selective  May be taken with or
Hydrochlorothiazide Antagonists OD pain, competitive without food
edema, angiotensin
 Diuretics Stock Dose: asthenia, 1 receptor
100 mg  Management Of
headache. antagonist
BN:Combizar Hypertension.
Palpitation. simply
Date started:
Diarrhea, inhibits
June 29 2009
nausea. indirectly
Contraindications: Back pain. some
Dizziness. substance
Dry cough, occur in our
sinusitis, body
 Contraindicated To Those
bronchitis, responsible
Who Are Hypersensitive To
pharyngitis, for water
Sulfonamides. Patients W/
upper resp retention
Anuria & Depleted
infection. thus by
Intravascular Volume As
Rash. decreasing
well as pregnant women.
body water
volume
lowers
blood
pressure

29
30
 GENERIC CLASSIFICATION DOSAGE, INDICATIONS/ SIDE EFFECTS MODE OF NURSING
ROUTE, ACTION RESPONSIBILITIES
FREQUENC CONTRAINDICATIONS
Y

GN:Mannito Diuretic,osmotic 75 ml every Indication; CNS: Dizziness, Elevates the • Assess for S&S
l 6 hours TIV headache,blurred osmolarity of of electrolyte
• Prevention and vision,seizures the glomerular imbalance and
Stock Dose: treatement of the filtrate, thereby dehydration
250 ml oliguric phase of CV: Hypotension hindering the • Monitor VS &
renal failure edema,thrombophebiti reabsorption of
Date started: I&O
• Reduction of s, tachycardia, chest water and
BN: June 29 2009 • You may
intracranial pain leading to a loss
Osmitol, experience the
pressure and of water and side effects.
Dermatologic:
resectisol treatment of sodium,
urticaria, skin necrosis • Report
cerebral edema; chloride create
with inflitration difficulty of
of elevated IOP an osmotic
breathing, pain
when the pressure GU: diuresis, urinary gradient in the
at the iv site,
cannot be lowered retention eye between
chest pain.
by other means plasma and
• Promotion of the GI: Nausea, anorexia, ocular fluids,
urinary excretion dry mouth, thrist thereby
of toxic reducing IOP,
Hematologic: fluid
substances creates an
and electrolyte osmotic effects,
imbalances, leading to
Contraindication hyponatremia decreased
Respiratory: swelling in
• Contraindicated
pulmonary congestion, posttransurethr
with anuria due to al prostatic
severe renal rhinitis
resection
disease.
31
• Use cautiously
with pulmonary
congestion, active
bleeding
XIII. Problem List

32
 RANK ACTUAL PROBLEM DATE IDENTIFIED DATE RESOLVED

1 Impaired circulation July 9 2009 Unresolved

2 Muscle weakness July 9 2009 Unresolved

3 Inability to do self-care July 9 2009 Unresolved

5 Producing incomprehensible July 9 2009 Unresolved

sounds

RANK POTENTIAL PROBLEM DATE IDENTIFIED DATE RESOLVED

1 Risk for Injury July 9 2009 UNRESOLVED

2 Risk for Aspiration July 9 2009 UNRESOLVED

XIV. Nursing Care Plans

Impaired Circulation

33
 NURSING
ASSESSMENT PLANNING INTERVENTIONS RATIONALE EXPECTED OUTCOME
DIAGNOSIS

S= Impaired cerebral Short term >Establish Rapport > To gain pt’s trust Short term objective:
tissue perfusion r/t objective: and coordination
After Nursing
vascular occlusion
After Nursing intervention, the pt.
The patient
intervention, the pt. shall be able to
manifested the ff: > To identify any
will demonstrate >Monitor Vital signs demonstrate increased
other deviations from
increased perfusion perfusion as
normal.
as individually individually appropriate
O=
appropriate
T-36.7
Long Term >Assist pt. in
P-68 Long Term Objective:
Objective: assuming
>To aid with proper
R-19 semifowler’s position After 2-3 days of
After 2-3 days of perfusion or flow of
BP- 130/80 w/ head midline. Nursing Intervention,
Nursing Intervention, blood (circulation or
the pt. shall be able to
GLASCOW COMA the pt. will be able o venous drainage).
demonstrate behaviors
scale: demonstrate
Eye opening = >Administer >To probably which may improve
to speech 3 behaviors which may
medications as decrease cardiac proper circulation such
• Verbal response improve proper
= ordered such as workload and in as compliance to health
circulation such as

34
 incomprehensib compliance to health antihypertensive or maximizing tissue management &
le 2
management & diuretics. perfusion therapies provided.
• motor response
= flexion 3 therapies provided.
(decorticate)
• Total GCS = 8
awake and >Encourage quiet >To conserve energy
disoriented which could aid in
and restful
lowering the O2
atmosphere.
tissue demand.

>Exercise caution in
>The t issues may
using hot or cold
have decreased
pads.
sensitivity due to
ischemia.

>Encourage use of >To decrease the

relaxation techniques tension level
or exercises.

35
 >Discuss the
importance of
>To retain heat or
preventing exposure
warmth efficiently
to cold or extreme
cold temp

>Discuss to the
patient’s SO the
>To promote
importance of care of
wellness
dependent limbs,
body hygiene, and
foot care when
circulation is
impaired.

NURSING INTERVENTION PROGRESS NOTE

36
PROBLEM: IMPAIRED CIRCULATION

DATE: JULY 09, 2009

ASSESSMENT:

ON THE FIRST DAY WE HANDLED OUR CLIENT, SHE HAS THE GLASCOW COMA SCALE, Eye opening = to speech 3
Verbal response = incomprehensible 2, motor response = flexion 3 (decorticate), Total GCS = 8 awake and disoriented. SHE IS SLEEPING
WHEN WE CAME INDISE THE ROOM.

INTERVENTION:

AFTER THE ASSESSMENT, WE ADVISED THE RELATIVES AND TEACH THE PROPER POSITIONING OF THE PATIENT, SEMI FOWLER’S
POSITION WITH HEAD MIDLINE.

EVALUATION:

THE CLIENT STILLS THE SAME EVEN WE DID OUR INTERVENTIONS.

Muscle weakness

37
 NURSING
ASSESSMENT PLANNING INTERVENTIONS RATIONALE EXPECTED OUTCOME
DIAGNOSIS

S= “ hindi sya
gasinong makagalaw”
Impaired physical Short Term >Establish Rapport > To gain pt’s trust Short Term
mobility Objective: and coordination Objective:
neuromuscular and
O= After Nursing After Nursing
Impaired and limited musculoskeletal
Intervention, the pt. Intervention, the pt.
coordination by impairment as > To identify any
weakness will be able to >Monitor Vital signs shall be able to
evidence by limited other deviations from
maintain increased maintain increased
Decreased muscle motor skills. normal.
strength strength and strength and function of
function of affected >Assess patient affected or
Muscle strength
RU=1/5 or compensatory condition compensatory part.
RL=3/5 >To determine any
part.
LU=4/5 other underlying
LL=4/5
cause of
manifestations
>Provide adequate Long Term Objective:
Long Term rest periods as well
After 2-3 days of
Objective: as comfort & safety > To prevent further
nursing intervention,

38
After 2-3 days of measures stress & fatigue the pt. shall be able to
nursing intervention, demonstrate behaviors
the pt. will be able to that enable resumption
demonstrate >Turn pt. slowly from of activities.
behaviors that side to side
> To provide proper
enable resumption
circulation of blood
of activities.
flow on both sides

>Determine pt. level

of mobility

>To assess functional

ability
>Assist pt. in his
activities

>To promote optimal

level of function
>Encourage
adequate intake of
fluids & Nutritious

39
 foods >Promotes well-
being and maximizes
energy production.
>Involve client’s

SO in care
>To assist in learning
ways of managing
problems of
immobility.

NURSING INTERVENTION PROGRESS NOTE

PROBLEM: MUSCLE WEAKNESS

40
DATE: JULY 09, 2009

ASSESSMENT:

ON THE FIRST DAY WE HANDLED OUR CLIENT HAS IMPAIRED AND LIMITED COORDINATION BY WEAKNESS AND DECREASED MUSCLE
STRENGTH.

INTERVENTION:

AFTER THE ASSESSMENT, WE MONITORED THE VITAL SIGNS, ASSESSED THE CLIENT’S CONDITION. WE ALSO PROVIED HER
ADEQUATE REST PERIODS AS WELL AS COMFORT AND SAFETY MEASURES. WE TURNED THE CLIENT SLOWLY FORM SIDE TO SIDE EVERY
2HOURS.

EVALUATION:

THE CLIENT STILLS THE SAME EVEN WE DID OUR INTERVENTIONS.

Inability to do self-care

41
 NURSING EXPECTED
ASSESSMENT PLANNING INTERVENTIONS RATIONALE
DIAGNOSIS OUTCOME

S= Self Care deficit r/t Short Term >Established Rapport > To gain trust of the Short Term
neuromuscular, Objective: patient and SO in Objective:
musculoskeletal order to acquire
After Nursing After Nursing
The patient impairment compliance with
Intervention, the pt. Intervention, the pt.
manifested the appropriate
will be able to shall be able to
following: treatments or
identify personal identify personal
teachings
resources which can resources which can
help in providing >Monitored Vital help in providing
O=
assistance. signs assistance.
> To identify any
Decreased muscle
other deviations from
strength
normal.
>Assessed patient
condition
Long Term Long Term
Objective: >To determine any Objective:
other underlying
After 2-3 days of After 2-3 days of
cause of
nursing intervention, nursing intervention,
>Provided adequate manifestations
the pt. will be able to

42
demonstrate rest periods as well the pt. shall be able to
techniques or as comfort & safety
> To prevent further demonstrate
changes to meet self measures
stress & fatigue techniques or changes
care needs.
to meet self care
needs.
>Turned pt. slowly
from side to side
> To provide proper
circulation of blood
>Determined pt. flow on both sides of
strengths and skills he body

>Assisted pt. in his >To assess degree of

activities disability

>To promote optimal

level of function
>Encouraged
adequate intake of

43
fluids & Nutritious
foods
>Promotes well-being
and maximizes
energy production.
>Provided time for
listening to patient
and SO, and provided
>To assist with the
privacy during
patient’s current
personal care
disability or
activities.
condition.
>Involved client’s

SO in care
>To assist in learning
ways of managing
problems of
immobility and for
providing appropriate
nursing care.

> Provided health

44
teachings and
support o the SO for
>To provide
care options
clarification
Reinforcement and
and periodic Review
by client/caregivers.

45
NURSING INTERVENTION PROGRESS NOTE

PROBLEM: INABILITY TO DO SELF-CARE

DATE: JULY 09, 2009

ASSESSMENT:

ON THE FIRST DAY WE HANDLED OUR CLIENT HAS DECREASED MUSCLE STRENGTH.

INTERVENTION:

AFTER THE ASSESSMENT, WE MONITORED THE VITAL SIGNS, ASSESSED THE CLIENT’S CONDITION. WE ALSO PROVIED HER
ADEQUATE REST PERIODS AS WELL AS COMFORT AND SAFETY MEASURES. WE TURNED THE CLIENT SLOWLY FORM SIDE TO SIDE EVERY
2HOURS, WE ALSO DETERMINED CLIENT’S STRENGTHS AND SKILLS.

EVALUATION:

THE CLIENT STILLS THE SAME EVEN WE DID OUR INTERVENTIONS.

46
Producing incomprehensible sounds

NURSING
ASSESSMENT PLANNING INTERVENTIONS RATIONALE EXPECTED OUTCOME
DIAGNOSIS

impaired verbal Short Term >Establish rapport >To gain pt’s trust Short Term
and/or written Objective: and coordination Objective:
S= “ Naungol lang
communication r/t
sya pag may After nursing int. the After the nursing
impaired cerebral
kailangan sya” pt will be able to intervention the pt shall
circulation, aphasia >To obtain baseline
verbalize or indicate >Monitor v/s verbalize or indicate
data
understanding of the understanding of
O= communication communication
difficulty and plans >Assess pt’s general difficulty and plans for
w/ muscle weakness >To note for the
for ways of handling. condition ways of handling
etiology or
Uses
incomprehensible precipitating factors
sounds that can lead to

With drooling of fever.

saliva Long Term >Note results of

>To assess
Objective: neurological testing
Difficulty in causative/contributin Long Term Objective:
such as EEG/CT scan
g factors

47
expressing needs After 3 days of and the likes After the nursing
nursing intervention intervention the pt shall
the pt will establish be able to establish
method of >Assess >To assess methods of
communication in environment factors causative/contributin communication in
which needs can be that may affect g factors which can be
expressed. ability to expressed.
communicate
>To assist client to
establish a means of
>Establish communication to
relationship with the express needs,
client , listening wants, ideas and
carefully and questions
attending to clients
verbal/nonverbal
expressions >Individuals may
talk more easily
>Maintain a calm,
when they are rested
unhurried manner,
and relaxed
provide sufficient

48
time for the client to
responds
>To attend pt’s
>Anticipate needs needs immediately
until effective
communication is
reestablished >For pt’s recovery
and to treat
>Administer due
underlying conditions
meds

49
NURSING INTERVENTION PROGRESS NOTE

PROBLEM: MUSCLE WEAKNESS

DATE: JULY 09, 2009

ASSESSMENT:

ON THE FIRST DAY WE HANDLED OUR CLIENT HAS IMPAIRED AND LIMITED COORDINATION BY WEAKNESS AND DECREASED MUSCLE
STRENGTH.

INTERVENTION:

AFTER THE ASSESSMENT, WE MONITORED THE VITAL SIGNS, ASSESSED THE CLIENT’S GENERAL CONDITION. WE NOTED THE
RESULTS OF NEUROLOGICAL TESTING SUCH AS EEG/CT SCAN, WE ASSESSED ENVIRONMENT FACTORS THAT MEY AFFECT ABILITY TO
COMMUNICATE.

EVALUATION:

THE CLIENT STILLS THE SAME EVEN WE DID OUR INTERVENTIONS.

50
POTENTIAL PROBLEM
Risk for Injury
NURSING DIAGNOSIS PLANNING
Risk for Injury Short Term Objective:
After nursing intervention the pt
will demonstrate behaviors,
lifestyle changes to reduce risk
factors and protect self from
injury
Long Term Objective:
After hospitalization, pt will be
free of injury
INTERVENTIONS
>Monitor v/s
>Assess pt’s general
condition
>Assess mood, coping
abilities, personality styles
RATIONALE EXPECTED OUTCOME
Short Term Objective:
>To obtain baseline The patient shall have
data demonstrated behaviors,
lifestyle changes to reduce
risk factors and protect
self from injury
>To note for the
etiology or Long Term Objective:
precipitating factors
that can lead to fever. The patient shall have
been free of injury.
51
 >that may result in
carelessness and
increased risk taking
without considerations
of consequences
>Identify interventions and
safety devices
>To promote safe
physical environment
and individual safety

>Encourage participation
in self-help programs, such
>To enhance self
as assertiveness training,
esteem. sense of
positive self image
worth

>raise the side rails of the

bed
>To promote safe
physical environment
and individual safety

>Frequent skin inspection

> To assess if there is
presence of pressure

52
>Use effective lighting ulcers.

>To promote safety

and easy scanning of
>Remind client to walk the environment.
slowly, ambulate

>To prevent injury due

>Keep things into right to slipping, and to
premises and clear the way promote safety.
going to the restroom
>To prevent injury and
promote safety.

53
Risk for Aspiration

NURSING DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EXPECTED OUTCOME

Risk for Aspiration Short term Short term objective:

objective:
>Monitored Vital signs > To identify any other The patient shall have
After Nursing deviations from normal. demonstrated
intervention, the pt. techniques to prevent
demonstrate aspiration.
techniques to >To assess if there is gag
prevent aspiration. >Note level of reflex or difficulty of
consciousness of swallowing. Long Term Objective:
surroundings, and
Long Term cognitive impairment. The patient shall have
Objective: experienced no
>To clear secretions aspiration aeb noiseless
After respirations, and clear
>Suction as needed
hospitalization, the breath sounds.
pt. will experience >to determine presence of
no aspiration aeb secretions
noiseless >Auscultate lung sounds

54
respirations, and
clear breath sounds.
>Give semisolid foods; >To prevent aspiration and
avoid pureed that may to aide swallowing effort.
increase risk of
aspiration.

>Provide very warm or >This activates

cold liquids temperature receptors in
the mouth that help to
stimulate swallowing.

>Refer to speech >To strengthen muscles

therapist and techniques to enhance
swallowing.

55
XV. Overall Progress Notes

On the 1st day of our duty, the patient was conscious but incoherent due to inability to speak and she is just producing incomprehensible

sounds whenever she wanted anything. We also noted that she has hemiphlagia on the right side of the body. She also had NGT on her right

nostril. As part of the nursing interventions, we took her vital signs which are as follows: Temp.= Afebrile, Pulse= 68, Respiratory= 19 and BP

of 130/80mmHg. The students also provided non pharmacological interventions such as positioning etc. They also provided health teachings

for the family of the client.

On the second day, the patient is still the same with what we observe yesterday, For her vital signs: Temp.= Afebrile, Pulse=82,

Respiratory= 23 and a BP of 130/80mmHg. The students performed again those interventions they’ve done with the client.

Overall, the patient’s condition is still the same.

56
57