INTRODUCTION

Cerebrovascular Accident is a sudden loss of function resulting from disruption of the blood supply to a part of the
brain. Stroke, also called brain attack or ischemic stroke, happens when the arteries leading to the brain are blocked
or ruptured. When the brain does not receive the needed oxygen supply, the brain cells begin to die, a stroke can
cause paralysis, inability to talk, inability to understand, and other conditions brought on by brain damage.
There are four types of stroke; Cerebral Thrombosis which is caused by blood clots. It is the most common type of
brain attack. It occurs when a blood clot (thrombus) forms and blocks blood flow in an artery leading to the brain
arteries primarily affected by atherosclerosis and more susceptible to blood clots. Most often occurs at night or in the
morning when blood pressure is low. Often preceded by a transient ischemic attack (TIA) or “mini-stroke”; Cerebral
Embolism occurs when a wondering clot (embolus) or some other particle forms in a blood vessel away from the
brain, usually in the heart. The clot then travels and lodges in an artery leading on the brain; Cerebral Hemorrhage
occurs when a defective artery in the brain busts; Subarachnoid Hemorrhage occurs when a blood vessel on the
surface of the brain ruptures and bleeds into the space between the brain and the skull.
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 more than 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.
According to the latest WHO data published in may 2014 Stroke Deaths in Philippines reached 63,261 or 12.14% of
total deaths. The age adjusted Death Rate is 119.21 per 100,000 of population ranks Philippines #54 in the world.
Review other causes of death by clicking the links below or choose the full health profile.
Stroke is the Philippines' second leading cause of death. It has a prevalence of 0.9%; ischemic stroke comprises
70% while hemorrhagic stroke comprises 30%. Age-adjusted hypertension prevalence is 20.6%, diabetes 6.0%,
dyslipidemia 72.0%, smoking 31%, and obesity 4.9%. The neurologist-to-patient ratio is 1:330,000, with 67% of
neurologists practicing in urban centers. Health care is largely private and the cost is borne out-of-pocket by patients
and their families. Challenges include delivering adequate support to the rural communities and to the
underprivileged sectors.

1
 I. ANATOMY AND PHYSIOLOGY
The Central Nervous System (CNS) is composed of the brain and spinal cord. The CNS is surrounded by bone-skull
and vertebrae. Fluid and tissue also insulate the brain and spinal cord.
Brain
Areas of the brain, the brain is composed of three parts: the cerebrum (seat of consciousness), the cerebellum, and
the medulla oblongata (these latter two are “part of the unconscious brain”). The medulla oblongata is closest to the
spinal cord and is involved with the regulation of heartbeat, breathing, vasoconstriction (blood pressure), and reflex
centers for vomiting, coughing, sneezing, swallowing and hiccupping. The hypothalamus regulates homeostasis. It
has regulatory areas for thirst, hunger, body temperature, water balance and blood pressure and links the nervous
system to the Endocrine System. The midbrain and pons are also part of the unconscious brain. The thalamus serves
as a central relay point for incoming nervous messages. The cerebellum is the second largest part of the brain, after
the cerebrum. It functions for muscle coordination and maintains normal muscle tone and posture. The cerebellum
coordinates balance. The conscious brain includes cerebral hemispheres, which are separated by the corpus
callosum.
The brain stem is the smallest and from an evolutionary viewpoint, the oldest and most primitive part of the brain. The
brain stem is continuous with the spinal cord, and is composed of the parts of the hindbrain and midbrain. The
medulla oblongata and pons control heart rate, constriction of blood vessels, digestion and respiration. The midbrain
consists of connections between the hindbrain and forebrain. The cerebellum is the third part of the hindbrain, but it is
not considered part of the brain stem. Functions of the cerebellum include fine motor coordination and body
movement, posture and balance. The forebrain consists of the diencephalon and cerebrum. The thalamus and
hypothalamus are parts of the diencephalon. The thalamus acts as a switching center for nerve messages. The
hypothalamus is a major homeostatic center having both nervous and endocrine functions. The cerebrum, the largest
part of the human brain, is divided into left and right hemispheres connected to each other by the corpus callosum.
The hemispheres are covered by a thin layer of gray matter known as the cerebral cortex.The cortex in each
hemisphere of the cerebrum is between 1and 4mm thick. Folds divide the cortex into four lobes: occipital, temporal,
parietal, and frontal. No region of the brain functions alone, although major functions of various parts of the lobes
have been determined. The occipital lobe (back of the head) receives and processes visual information. The temporal
lobe receives auditory signals, processing language and the meaning of words. The parietal lobe is associated with
the sensory cortex and processes information about touch, taste, pressure, pain, and heat and cold. The frontal lobe
conducts three functions; motor activity and integration of muscle activity, speech, thought processe. Language
comprehension is found in Wernicke’s area. Speaking ability is in Broca’s area.
Blood Vessels of the Brain
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 most of the anterior portion of the cerebrum. The vertebrobasilar arteries
supply the posterior two-fifths of the cerebrum, part of the cerebellum, and the brain stem.

2
Circle of Willis, at the base of the brain, the carotid and vertebrobasilar arteries form a circle of communicating
arteries known as the Circle of Willis. From this circle, other arteries—the anterior cerebral artery (ACA), the middle
cerebral artery (MCA), the posterior cerebral artery (PCA)—arise and travel to all parts of the brain.
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 of the legs.
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 posterior arteries supply the
temporal and occipital lobes of the left cerebral hemisphere and the right hemisphere.
Cranial Nerves
The cranial nerves are a set of 12 paired nerves that arise directly from the brain. The first two nerves (olfactory and
optic) arise from the cerebrum, whereas the remaining ten emerge from the brain stem.
There are twelve cranial nerves in total. The olfactory nerve (CN I) and optic nerve (CN II) originate from the
cerebrum. Cranial nerves III – XII arise from the brain stem. They can arise from a specific part of the brain stem
(midbrain, pons or medulla), or from a junction between two parts:
Midbrain-pontine junction – oculomotor (III).
Midbrain – the trochlear nerve (IV) comes from the posterior side of the midbrain. It has the longest intracranial length
of all the cranial nerves.
Pons – trigeminal (V).
Pontine-medulla junction – abducens, facial, vestibulocochlear (VI-VIII).
Medulla Oblongata – posterior to the olive: glossopharyngeal, vagus, accessory (IX-XI). Anterior to the olive:
hypoglossal (XII).
The cranial nerves are numbered by their location on the brain stem (superior to inferior, then medial to lateral) and
the order of their exit from the cranium (anterior to posterior); (CNI) Olfactory, (CNII) Optic, (CNIII) Oculomotor,
(CNIV) Trochlear, (CNV) Trigeminal, (CNVI) Abducens, (CNVII) Facial, (CNVIII) Vestibulocochlear,
(CNIX)Glossopharyngeal, (CNX) Vagus, (CNXI) Spinal accessory, (CNXII) Hypoglossal

3
4
II. PATHOPHYSIOLOGY

Precipitating factors
Predisposing factors High fat and glucose
Age (71 yrs old) consumption
Gender (Male) History of CVA infarct 9/17
History of HP and DM

Deposition of Atheroclerotic
plaque
5

Decrease blood supply in the

Obstruction
Thrombus
in the
Platelet formation
blood vessel
adhesion Brain
 Large occlusion in the carotid
artey

Compensatory mechanism
HR: 105 bpm
Cerebral
PonsHypoxia
& Medulla PR: 125 bpm
(Hgb: Oblongata
126/L)

Ischemia

Necrosis of neurons Ventricular Tachycardia

Infarction @ Right Middle

cerebral artery Exhaustion of cardiac muscle

Left side weakness

and numbness
Pons Decrease of LOC
6
 Left sided Stiffness in the cardiac muscles
hemipharesis
CN VII
CN V, IX, X
Impaired physical Stuporous
mobility GCS 11/15 Left ventricular hypertrophy
2d echo:
Facial spasm LVESD: 2.9 (1.4-2.1cm/m2)
LVEDD: 3.4 (3.2cm/m2)
Decrease muscle Xray: cardiomegaly
function for Prolonged pressure
swallowing of affected side
Facial Left ventricular relaxation
assymetry ECG: QRS widening
LEFT BUNDLE BRANCH BLOCK

Redness and heat

(-) Gag reflex
Sluggish
speech Left ventricular failure

Decrease in ejected blood

Decrease tissue volume
integrity 2d echo:
CO: 1.8 (4.5 L/m)
EF: 35% (55%)
SV: 17ml (>65 mL
Ulceration HYPOVOLEMIA

Over pooling of blood in the left

ventricle 7
Bed sores

Congestion in the LV

CHF

Regurgitation in the mitral valve

Pulmonary congestion

8
 III. ASSESSMENT
1. Personal Data
PATIENT PROFILE
Name : Mr. JNG
Age : 71 years Old
Gender : Male
Nationality : Filipino
Religion : Catholic
Date of Birth : November 28, 1946
Place of Birth : Manila
Civil Status : Married
Educational Attainment : College Graduate
Occupation : Retired
Date and Time of Admission : February 2, 2018 (1200H)
Date handled and assessed : February 6-7, 2018
Admission no : 26666
Ward/Room/Bed : 5A, Room Number 528
Attending Medical Doctor : Dr. Jo – Ann Khow
Chief Complaint : Facial Asymmetry
Admitting Diagnosis : CVA Infarction
Contact Person/Informant : SP
Percentage of reliability of the Resource: Chart (70%) SP (30%)

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 2. Family Background
GENOGRAM

PATERNAL SIDE MATERNAL SIDE

UNKNOWN

UNKOWN UNKOWN
UNKNOWN UNKOWN

CVA Pt’sMother DM UNKNOWN UNKNOWN

DM and HPN Pt’s Father

69
71 DM 67
CVA
HPN
HPN
DM

LEGENDS:
Female Deceased

= Male Patient
HPN- Hypertension
DM- Diabetes Mellitus
CVA- Cardio Vascular Accident

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GENOGRAM INTERPRETATION:
In client’s paternal side, both grandfather and grandmother were already dead because of unknown reason. Mr. J.G’s father has one sibling and is already dead due to Diabetes Mellitus and
Hypertension and his father himself died from CVA. In maternal side, also both grandmother and grandfather were already dead due to unknown reason. His mother has two brothers and all of them
were dead already due to unknown reasons, also the client’s mother was already dead because of Diabetes Mellitus. Mr. J.G. has two siblings, one sister and one brother. His youngest sister has
hypertension and his brother has Diabetes Mellitus.
Mr. J.G has CVA, Diabetes Mellitus, and Hypertension.

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 3. Health History

A. Family Health History

GENOGRAM

B. Past Health History

Mr. JNG was fully immunized since he was young. He had a mumps and chicken pox when he was 15 years old. Has
a history of hypertension 30 years ago up to now maintained on Sacubitril/Valsartan 500mg ½ tab OD and Carvedilol
PRN, Cardiovascular disease maintained on Spironolactone 25mg ½ tab OD, Diabetes maintained on Empagliflozin
10mg/tab OD, s/p TURP left, s/p CVA Infarct 2017 with right residuals MRS3 maintained on Clopidogrel 75mg OD
and Atorvastatin 40mg OD. No history of PTB, Bronchial Asthma. No allergies to foods and medications. Brain attack
three times, 2015, 2017 and this year.

C. Present Health History

2 hours prior to admission (0700H) while doing routine aerobic exercise patient had onset coughing and and facial
asymmetry on the right with associated slurring of speech. No noted loss of consciousness, seizure, nor difficulty of
breathing. No medications given. Symptoms prompted ER consult and subsequent admission.

D. Lifestyle and Personal History

Mr. JNG is living with his wife and daughter, his daughter’s family. (Extended) He goes to church when he has free
time. He considered church time as his quality time with God.

When it comes to his diet, Mr. JNG loves to eat fatty foods like lechon, bulalo, sweet foods his favorite dessert is
leche flan and fruit salad and etc Patient was an alcohol drinker when he was young up to 33 yearls old and stopped
when he was 34 he think. He was a previous smoker he started to smoke when he was 19 years old and stopped
smoking when he was 45 years old. Denied illicit drug use.

When it comes to health care matters, our institution is their main hospital, Metropolitan Medical Center.
Mr. JNG goes to MMC every month for regular check up with his physician

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 4. Developmental Data
a. Erik Erickson

A. Erik Erickson’s Psychosocial Developmental Stage

 Stage 8, Later Adulthood: 71
 Ego Development Outcome: Integrity Vs. Despair
 Basic strengths: Wisdom
The integrity versus despair stage begins as the aging adult begins to tackle the problem of his or her mortality.
The onset of this stage is often triggered by life events such as retirement, the loss of a spouse, the loss of friends
and acquaintances, facing a terminal illness, and other changes to major roles in life.
During this period, people reflect back on the life they have lived and come away with either a sense of fulfillment
from a life well lived or a sense of regret and despair over a life misspent.
Successfully resolving the crisis at this stage leads to the development of what Erikson referred to as ego integrity.
People are able to look back at their life with a sense of contentment and face the end of life with a sense of wisdom
and no regrets. Erikson defined this wisdom as an "informed and detached concern with life itself even in the face of
death itself."
Those who feel proud of their accomplishments will feel a sense of integrity. Successfully completing this phase
means looking back with few regrets and a general feeling of satisfaction. These individuals will attain wisdom, even
when confronting death.
Those who are unsuccessful during this phase will feel that their life has been wasted and will experience many
regrets. The individual will be left with feelings of bitterness and despair.

Developmental Aspect Mr. JNG Analysis

Physical Development
According to the patient’s caregiver There is a big changes in his
he can perform activities of daily physical ability because of present
living such as eating, grooming, condition. Before and during his
bathing, playing computer games illness he can perform his activity of
with his son and exercise through daily living but during hospitalization
walking. During illness he can still he can no longer do his activities
do his activities of daily living. due to his illness.
During Hospitalization the patient
cant do his activities of daily living
such as eating alone, bathing and
grooming because of the present
condition. On stupurous state.

Psychosocial Development
Erik Erickson adapted and expand Freud theory of development to include the entire life span believing that people
continue to develop throughout life, he believed in the massive influenced of culture on behavior and placed more
emphasis on the external words such as depression and was to his theory, each stage signals that a task must be
achieved.
Developmental Aspect Mr. JNG Analysis
Psychosocial Development According to his caregiver, Mr. JNG Mr. JNG has successfully achieved
is a loving father to his son and of having a family he was now
daughter, as well as in his committed with his wife and
grandchildren. Mr. JNG love to go to children. They are living with a
church almost every day because at happy and contented life. He
home he do nothing but eat and maintained a good communication
sleep. with his relatives.

13
Cognitive Development
It refers to the manner in which people learn to think reason and use language. It involves the person’s
intelligence, perceptual ability to process information. The widely known cognitive theorist jean piaget who formulates
cognitive development were he states that a progression of mental abilities from illogical to logical thinking. From
simple to complex from solving and understanding.
Developmental Aspect Mr. JNG Analysis
Cognitive development Mr. JNG finished college, and In this aspect, there is a significant
manage their family business. And increase in his intellectual abilities
by experience the client has more because of the influence of his field
knowledge to share with his of work
workers.

Moral Development
It refers to a complex process not fully understood. Involves learning what ought to be and what is not ought
to be done, and moral means relating to right and wrong and according to Kohlberg this is the reason on how
individuals decide.
Developmental Aspect Mr. JNG Analysis
Moral Development Mr. KVA was able to achieve In this aspect, he was able to define
intimacy because he is now a good and bad relation to self, he
husband and a father and a seems happy but with no sense of
grandfather, he has his own family. completeness because he was
He is happy of what he achieved but thinking of the future of his children
he knows that he has more he wants them to have a happy life.
responsibilities to his wife and He was able to obtain following
children. He seemed contented with society’s rules of conduct in
what he had but he want to give a response to the expectation of
happy and good life to his children. others.

Spiritual Development
It refers to the growth and development of an individual to their relationship with the universe and their
perceptions about the direction and meaning of life according to James fowler that gives meaning to a persons’ life.
Developmental Aspect Mr. JNG Analysis
Spiritual Development Mr. JNG is a catholic and go to He was able to derive a sense of
church every day and considered as worth by sharing experiences or
his quality time with God. views. He took her devotional tie
privately and considered his church
time as a quality time with God.

ANALYSIS:
Mr. JNG achieved the stage 8 of Erik Erickson’s theory. He is a married man now with loving children. A
grandfather to his daughter and son’s children. He seems happy and contended what he achievedin his life.

B. Robert Havighurst
14
Havighurst’s Developmental Tasks Theory

Havighurst’s main assertion is that development is continuous throughout the entire lifespan, occurring in stages,
where the individual moves from one stage to the next by means of successful resolution of problems or performance
of developmental tasks. These tasks are those that are typically encountered by most people in the culture where the
individual belongs. If the person successfully accomplishes and masters the developmental task, he feels pride and
satisfaction, and consequently earns his community or society’s approval. This success provides a sound foundation
which allows the individual to accomplish tasks to be encountered at later stages. Conversely, if the individual is not
successful at accomplishing a task, he is unhappy and is not accorded the desired approval by society, resulting in
the subsequent experience of difficulty when faced with succeeding developmental tasks. This theory presents the
individual as an active learner who continually interacts with a similarly active social environment.
Havighurst proposed a bio psychosocial model of development, wherein the developmental tasks at each stage are
influenced by the individual’s biology (physiological maturation and genetic makeup), his psychology (personal values
and goals) and sociology (specific culture to which the individual belongs).
Some developmental tasks evolve out of the biological character of humans and are therefore faced similarly by all
individuals from any culture. An example of this is learning how to walk for infants. Being a skill that depends on
maturation and genetically determined factors, the mechanics involved in learning how to walk are virtually the same
and occur at generally the same time for children from all cultures.
Other tasks that stem from biological mechanisms include learning to talk, exercising control over bodily functions,
learning skills typically utilized in children’s games, and coping with physiological changes related to aging, to name a
few. Havighurst stressed the importance of sensitive periods which he considered to be the ideal teachable moments
during which an individual demonstrates maturation at a level that is most conducive to learning and successfully
performing the developmental tasks.

Later Adulthood Mr. JNG Analysis

Adjusting to deteriorating health and N/A N/A
physical strength

Adjusting to retirement He already retired but managing Patient successfully adjusted to retirement.
family business in the present.
Meeting social and civil obligations N/A N/A

Adjusting to death or loss of spouse Mr. JNG’s wife is living with him. .

Analysis:
N/A

5. PATTERNS OF FUNCTIONING

15
Pattern of Before Illness During Illness During Analysis
Functioning Hospitalization

Eating Pattern Breakfast: Breakfast: Nutren DM 200cc every The eating pattern of the
The client usually The client usually dont 6 hours (NGT) client has been greatly
dont eat breakfast. eat breakfast. Usually a affected because of the
Usually a cup of cup of coffee occurrence of his
coffee disease. Before and
Lunch: during his illness he was
Lunch: 5 cups of rice, pork able to eat because he
5 cups of rice, pork (pork belly usually) with was not aware that he
(pork belly usually) sarsa Sometimes he has the said disease.
with sarsa eats fish with 3 glasses During hospitalization,
Sometimes he eats of water he feed with Nutren DM
fish with 3 glasses 200cc every 6 hours
of water Dinner: (NGT)
3 cup of rice and
Dinner: pork/beef/fish.
3 cup of rice and 2 glasses of water.
pork/beef/fish.
2 glasses of water.

Drinking Pattern Mr. JNG can Mr. JNG can Diet: Nutren DM Before the
consumed 8 or more consumed 8 or more 200cc every 6 hours occurrence of the
glasses of water a glasses of water a (NGT) client’s illness he
day. day. was able to
. consumed 8 or more
glasses of water per
day. There is
significant change in
drinking pattern of
the client

16
Pattern of Before Illness During Illness During Analysis
Functioning Hospitalization

Elimination FREQUENCY: FREQUENCY: FREQUENCY: The client’s

Pattern 5-6 times a week 5-6 times a week 5-6times a week elimination pattern is
(1-2 times a day) (1-2 times a day) (1-2time a day) normal before,
during and during
COLOR: COLOR: COLOR: hospitalization was
Brown Brown Yellowish changed.

CONSISTENCY: CONSISTENCY: CONSISTENCY:

Moist, semi-solid Moist, semi-solid Moist, slighty watery
moderate in moderate in amount. moderate in amount.
amount.

Pattern of Before Illness During Illness During Analysis

Functioning Hospitalization

Urination Pattern FREQUENCY: FREQUENCY: FREQUENCY: The urinary

5-6 times a day 5-6 times a day With FCTUB frequency was
COLOR: COLOR: COLOR: changed.
Yellowish Yellowish Yellowish
OUTPUT: OUTPUT: OUTPUT:
>1400 ml >1400 ml >60 ml approximately
approximately per approximately per per hr.
moderate in amount. moderate in amount.

Pattern of Before Illness During Illness During Analysis

Functioning Hospitalization

Bathing Pattern Before illness he During Illness he he Staff nurses and The bathing
can do bathing can do bathing student nurse pattern was
alone regularly. alone regularly. sponge bath the changed and it
client became frequently
due to health
condition.

Pattern of Before Illness During Illness During Analysis

Functioning Hospitalization

Sleeping Pattern Mr. JNG usually Mr. JNG usually N/A The client’s
sleeps 6-7 hours per sleeps 6-7 hours per sleeping was
day day changed because
of the altered level
of conciousness

17
 6. LEVEL OF COMPETENCIES
PHYSICAL
Before Illness During Illness
According to the patient
before his illness he can
perform activities of daily
living such as eating,
grooming, bathing, go to
work every day and
exercise through walking.
SOCIAL
Before Illness
According to his caregiver
Mr. JNG is approachable
and loveable.
INTELLECTUAL
Before Illness
Mr. JNG finished his
college. He can
communicate with his
workers and friends. He
can solve simple problem
without any pressure.
During illness he can still
do his activities of daily
living and can work
properly with his co-
workers.
During Illness
According to his caregiver
Mr. JNG is approachable
and loveable. He spends
his time chatting with his
workers, family, children
and relative also.
During Illness
There is no change in his
daily routine and
intellectual matter
because he is not aware
of the present condition.
During Hospitalization
During Hospitalization the
patient cannot perform
activity of daily living. But
he has his caregiver.
During Hospitalization
N/A
During Hospitalization
N/A
Analysis
There is a change in his
physical ability because of
present condition. Before
his illness he can perform
his activity of daily living
and during illness. During
hospitalization due to his
illness he was not able to
do his daily routine.
Analysis
Mr. JNG is a happy person
and approachable but
during the illness and
hospitalizatiom has
changed.
Analysis
Before and during illness
the client achieved the
intellectual matter of his
life but duing
hospitalization due to
Altered level of
consciousness the data is
not applicable.
18
EMOTIONAL
Before Illness During Illness
“mabait ‘yan at There is no change in his
masiyahin.” as verbalized emotional state because
by his caregiver.. he was not aware of the
present condition.
SPIRITUAL
Before Illness During Illness
According to his caregiver During illness, Mr. JNG is
the client is not a fan of become fan of going to
going to church church everyday and
considered his quality time
with God.
During Hospitalization Analysis
N/A. Befoe and duing illness the
people around him can
determine wether if he is
sad or happy but now
because of his present
condition they cant identify.
During Hospitalization Analysis
Mr.JNG wasn’t able to go There is a change when it
to church because of the comes to his spirituality.
present condition.
19
 7. Physical Assessment Date assessed: 02-09-
18

Appearance:On stuporous state, lying on semi-fowlers position with an ongoing IVF of PNSS infusing well via left
metacarpal vein regulated at 42cc/hr. With O2 inhalation of 2lpm via nasal cannula. With Nasogastric tube. With
Foley Catheter to Urine Bag draining yellow amber. Patient is fatigue and experiencing body weakness. Patient’s
NVS is hourly monitored, during admission he had a result of GCS-14/15 while on the remaining days he had a
score of GCS-11/15.

Vital Signs: BP – 100/60mmHg; T – 36.7C; PR – 105bpm; RR – 23cpm; O2 - 94%

BODY TECHNIQU NORMAL ACTUAL ANALYSIS

PARTS E FINDINGS FINDINGS
USED
Inspection Whitish pink or brown in color, dark Pale Abnormal
skin tone depending on patient’s d/t decreased
race; no evidence of discoloration. tissue perfusion
No lesions except for birthmarks or and peripheral
nevi. vasoconstriction

Wrinkled Normal
d/t loss of elastic
fiber and
decreased
subcutaneous fat
from hypodermis
secondary to
SKIN aging

Presence of Abnormal
bedsore (Grade 1) d/t prolonged
Pinched-up skin returns to its pressure on the
original position immediately. skin
Dry with minimum perspiration;
smooth, even and firm; no edema Dry skin Normal
present. d/t decreased
activity of
sebaceous and
sweat glands
secondary to
Palpation aging

Sagged Normal
d/t loss of elastic
fiber and
decreased
subcutaneous fat
from hypodermis
secondary to
aging
Color varies from dark black to White in color Normal
pale; evenly distributed; no lesions d/t decreased
in scalp; thin, coarse, straight, thick melanocyte
or curly hair. production
HAIR Inspection secondary to
aging

Thin and not Normal

evenly distributed d/t aging
Inspection Pink to brown cast, flat and slightly Pallor Abnormal
rounded. d/t poor arterial

20
 Nails circulation

Palpation 2-3 seconds capillary refill; smooth Capillary refill Abnormal

within 4 seconds d/t poor arterial
circulation

Inspection Normocephalic and symmetrical Normocephalic &

symmetrical
Head Normal
Palpation smooth, nontender without masses. Nontender,
without masses
Facial features should be Facial asymmetry Abnormal
symmetrical; shape can be round, d/t damage of the
Face Inspection oval or slightly squared; no upper motor
involuntary movements; no edema neurons of the
and disproportion. facial nerve

Inspection Symmetrical neck muscles; head in Not able to Abnormal

full ROM without discomfort perform ROM d/t muscle
Neck without assistance atrophy

Palpation No palpable masses or No palpable lymph Normal

enlargement of lymph nodes and nodes
thyroid glands.
Eyes are aligned; no involuntary Anicteric sclera, Normal
movement of either eyes pink palpebral
Both eyes move smoothly and conjunctiva
symmetrically in each 6 cardinal
sides
No drooping, infections or tumors
Eyes Inspection Pink and moist conjunctiva
Pupil – deep black; round, and
equal in diameter.
The patient has no hearing difficulty No hearing
Ears Inspection difficulty Normal
Symmetrical in the midline of the With Nasogastric Normal
Nose Inspection face; no lesion, swelling, bleeding tube and O2 d/t therapeutic
and masses inhalation via regimen
nasal cannula
Inspection Lips – pink and moist with no Pale Abnormal
evidence of lesions or inflammation d/t decrease
Tongue – midline in the mouth; oxygenation
pink, moist and rough; no lesions
and swelling. Dry lips Abnormal
Gums – pale red; no swelling or d/t decreased
bleeding. salivary
production r/t
Mouth loss of vagal
stimulation

Sluggish speech Abnormal

(slow speech that d/t stroke
can be difficult to secondary to
understand) facial paralysis

Inspection No accessory muscles are used in With Nitroglycerin Normal

normal breathing patch d/t therapeutic
CHEST & Symmetrical Chest Expansion regimen
ThoraCIC No retractions
Palpation
Vesicular Breath Sounds

21
 Auscultation No Crackles on both lungs Clear breath Normal
sounds
Inspection/ Flat or rounded; Flat, soft,
Palpation/ Symmetrical bilaterally; normoactive Normal
Abdomen Auscultation No discoloration bowel sounds,
soft, non-tender

Inspection Able to perform full ROM Left arm not able Abnormal
No lesion, swelling or inflammation to perform full d/t decreased
ROM function of the
UPPER Full and equal pulse on all motor response
EXTREMITIE extremities
S Palpation Normal
No present edema
Inspection Able to perform full ROM Not able to Abnormal
No lesion, swelling or inflammation perform full ROM d/t decreased
function of the
motor response
LOWER Full and equal pulse on all
EXTREMITIE Palpation extremities, no edema present No present edema Normal
S

22
 GLASGOW COMA SCALE
DATE: 02-02-18

EYE OPENING SCOR 8 9 10 11 12 13 14 16 17 18

AM SHIFT PM19SHIFT
20 21 22 24 01 02 03
NIGHT 04 05
SHIFT 06
E
Spontaneous 4 /
In response to speech 3 / / / / / / / / / / / / / / / / / / /
In response to pain 2
None 1

BEST VERBAL RESPONSE

Oriented conversation 5
Confused conversation 4 / /
Inappropriate words 3
Incomprehensive sounds 2 / / / / / / / / / / / / / / / / / /
None 1

BEST MOTOR RESPONSE

Obeys 6 / / / / / / / / / / / / / / / / / / /
Localizes 5
Withdraws 4
Abnormal flexions 3
Abnormal extension 2
None 1

TOTAL 15 14 13 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11

DATE: 02-03-18
AM SHIFT PM SHIFT NIGHT SHIFT
EYE OPENING SCOR 8 9 10 11 12 13 14 16 17 18 19 20 21 22 24 01 02 03 04 05 06
23
 E
Spontaneous 4
In response to speech 3 / / / / / / / / / / / / / / / / / / / /
In response to pain 2
None 1

BEST VERBAL RESPONSE

Oriented conversation 5
Confused conversation 4
Inappropriate words 3
Incomprehensive sounds 2 / / / / / / / / / / / / / / / / / / / /
None 1

BEST MOTOR RESPONSE

Obeys 6 / / / / / / / / / / / / / / / / / / /
Localizes 5
Withdraws 4
Abnormal flexions 3
Abnormal extension 2
None 1

TOTAL 15 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11

DATE: 02-04-18
AM SHIFT PM SHIFT NIGHT SHIFT
EYE OPENING SCOR 8 9 10 11 12 13 14 16 17 18 19 20 21 22 24 01 02 03 04 05 06
E
Spontaneous 4
24
In response to speech 3 / / / / / / / / / / / / / / / / / / / /
In response to pain 2
None 1

BEST VERBAL RESPONSE

Oriented conversation 5
Confused conversation 4
Inappropriate words 3
Incomprehensive sounds 2 / / / / / / / / / / / / / / / / / / / /
None 1

BEST MOTOR RESPONSE

Obeys 6 / / / / / / / / / / / / / / / / / / /
Localizes 5
Withdraws 4
Abnormal flexions 3
Abnormal extension 2
None 1

TOTAL 15 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11

DATE: 02-05-18
AM SHIFT PM SHIFT NIGHT SHIFT
EYE OPENING SCOR 8 9 10 11 12 13 14 16 17 18 19 20 21 22 24 01 02 03 04 05 06
E
Spontaneous 4
In response to speech 3 / / / / / / / / / / / / / / / / / / / /
In response to pain 2
25
None 1

BEST VERBAL RESPONSE

Oriented conversation 5
Confused conversation 4
Inappropriate words 3
Incomprehensive sounds 2 / / / / / / / / / / / / / / / / / / / /
None 1

BEST MOTOR RESPONSE

Obeys 6 / / / / / / / / / / / / / / / / / / /
Localizes 5
Withdraws 4
Abnormal flexions 3
Abnormal extension 2
None 1

TOTAL 15 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11

DATE: 02-06-18
AM SHIFT PM SHIFT NIGHT SHIFT
EYE OPENING SCOR 8 9 10 11 12 13 14 16 17 18 19 20 21 22 24 01 02 03 04 05 06
E
Spontaneous 4
In response to speech 3 / / / / / / / / / / / / / / / / / / / /
In response to pain 2
None 1
26
BEST VERBAL RESPONSE

Oriented conversation 5
Confused conversation 4
Inappropriate words 3
Incomprehensive sounds 2 / / / / / / / / / / / / / / / / / / / /
None 1

BEST MOTOR RESPONSE

Obeys 6 / / / / / / / / / / / / / / / / / / /
Localizes 5
Withdraws 4
Abnormal flexions 3
Abnormal extension 2
None 1

TOTAL 15 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11

DATE: 02-07-18
AM SHIFT PM SHIFT NIGHT SHIFT
EYE OPENING SCOR 8 9 10 11 12 13 14 16 17 18 19 20 21 22 24 01 02 03 04 05 06
E
Spontaneous 4
In response to speech 3 / / / / / / / / / / / / / / / / / / / /
In response to pain 2
None 1

BEST VERBAL RESPONSE

27
Oriented conversation 5
Confused conversation 4
Inappropriate words 3
Incomprehensive sounds 2 / / / / / / / / / / / / / / / / / / / /
None 1

BEST MOTOR RESPONSE

Obeys 6 / / / / / / / / / / / / / / / / / / /
Localizes 5
Withdraws 4
Abnormal flexions 3
Abnormal extension 2
None 1

TOTAL 15 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11

28
 INTAKE AND OUTPUT MONITORING SHEET
02-02-18
Intake Output
Time IVF Oral TOTAL Urine Vomitus/Etc. TOTAL
1000H-1400H 430 210 640 230 230
1600H-2200H 500 210 710 260 260
2400H-0600H 600 210 810 385 385
TOTAL = 2160 TOTAL = 875
02-03-18
Intake Output
Time IVF Oral TOTAL Urine Vomitus/Etc. TOTAL
0800H- 600 420 1020 320 320
1400H
1600H- 500 520 1020 260 260
2200H
2400H- 550 520 1070 358 358
0600H
TOTAL = 3110 TOTAL = 938
02-04-18
Intake Output
Time IVF Oral TOTAL Urine Vomitus/Etc. TOTAL
0800H- 400 420 820 410 410
1400H
1600H- 410 460 870 530 530
2200H
2400H- 320 520 840 690 690
0600H
TOTAL = 2530 TOTAL = 1630
02-05-18
Intake Output
Time IVF Oral TOTAL Urine Vomitus/Etc. TOTAL
0800H- 300 520 820 600 600
1400H
1600H- 300 560 780 520 520
2200H
2400H- 350 520 870 360 360
0600H
TOTAL = 2470 TOTAL = 1480
02-06-18
Intake Output
Time IVF Oral TOTAL Urine Vomitus/Etc. TOTAL
0800H- 300 520 820 500 500
1400H
1600H- 300 520 820 380 380
2200H
2400H- 300 520 820 440 440
0600H
TOTAL = 2460 TOTAL = 1320

02-07-18
Intake Output
Time IVF Oral TOTAL Urine Vomitus/Etc. TOTAL
0800H- 300 540 840 490 490
1400H
1600H- 300 520 820 780 780
2200H
2400H- 300 520 820 670 670
0600H
TOTAL = 2480 TOTAL = 1940

29
 8. ON GOING APPRAISAL

February 5, 2018
First day of nursing care was given to the client at Metropolitan Medical, 5B ward Room No. 528. At 0700H the client
was handled, received on stuporous state lying on semi-fowlers position with an IVF of PNSS 1L at 900cc level
infusing well via left metacarpal vein at 14 gtts./min. Patient was on NGT feeding and has an O2 inhalation via nasal
cannula at 2lpm. Patient was with Foley catheter to Urine Bag. Vital signs were monitored every hour also the neuro-
vital signs were recorded and I & O quantitatively. At 0800H prescribed medications was given thru NGT. Had done
AM care at 0900H. At 1000H performed oral suction prior to NGT feeding. Do oral care to the client at 1200H. Before
the shift ends all the data (I = 820 including the NGT and intravenous fluid and O = 500) was charted down. All the
nursing responsibilities that had been done were consulted by the clinical instructor first before doing anything.

February 6, 2018
Second day that we rendered care and the last day that we handled the client was received on stuporous
state lying on semi-fowlers position with an IVF of PNSS 1L at 850cc level infusing well via left metacarpal vein at 14
gtts./min. Patient was on NGT feeding and has an O2 inhalation at via nasal cannula at 2lpm. Patient was with Foley
catheter to Urine Bag. Vital signs were monitored every 4hrs and neuro-vital signs hourly. I & O were monitored
quantitatively. Had done AM care at 0900H. At 1000H performed oral suction prior to NGT feeding and has given
prescribed medication, performed oral care after feeding. At 1200H initial I & O were been recorded and endorsed to
the nurse in charge. All the nursing responsibilities that had been done were consulted by the clinical instructor first
before doing anything.

30
 9. Laboratory Works
URINALYSIS
DEFINITION: An examination of the urine to determine the general health of the body and, specifically, kidney
function, usually including measurement of pH, tests for protein, glucose, ketones, and blood, and microscopic
evaluation of sediment obtained by centrifugation.
PRE PROCEDURE:
1.Explain Procedure to the patient
2.Instruct patient to void directly into a clean clear dry container
POST PROCEDURE:
1.Send specimen to laboratory

Patient Name: Mr. J.N.G Room: 528

Sex: M Reffering Physician: Dr. Jo-Ann Khow
Age: 71 Years old Date Released: 02/02/2018

MACROSCOPIC
Color YELLOW
Transparency CLEAR
Reaction 5.0
Specific Gravity 1.020

CHEMICAL TESTS
Protein NEGATIVE
Sugar +4
Ketone NEGATIVE
Urobilinogen NORMAL
Bilirubin NEGATIVE
Nitrite NEGATIVE
Erythrocytes +1
Leukocytes NEGATIVE

MICROSCOPIC
RBC 4-6
Pus Cells 0-2
Epithelial Cells RARE
Mucus threads FEW
Bacteria OCCASIONAL

Renal Cells NONE

Crystals NONE

Casts
Fine granular NONE
Coarse granular NONE
Hyaline NONE

ANALYSIS
Presence of glucose in urine is also called as glycosuria
A high count of RBC in urine can indicate infections or trauma
Presence of pus cells in urine is also called as pyuria

31
 BLOOD CHEMISTRY
DEFINITION: This is to measure levels of important electrolytes and other chemicals.
NURSING RESPONSIBILITY
PRE-PROCEDURE:
1.Explain procedure to the patient
POST PROCEDURE:
1.Send the specimen in the laboratory

Patient Name: Mr. J.N.G Room: 528

Sex: M Reffering Physician: Dr. Jo-Ann Khow
Age: 71 Years old Date Released:

TEST CONVENTIONAL UNIT S.I UNITS

RESULT REFERENCE RESULT REFERENCE

BUN 14.89 mg/dL 8-26 5.3 mmol/L 2.9-9.3
Creatinine 0.89 mg/dL 0.64-1.27 79 umol/L 57-113
Potassium 4.10 meq/L 3.6-5.1 4.1 mmol/L 3.6-5.1
Sodium 140.00 meq/L 136-144 140 mmol/L 136-144

ANALYSIS:
All results are NORMAL

LIPID PROFILE
32
 DEFINITION:This is a panel of blood tests that serves as an initial broad medical screening tool for abnormalities
inlipds.
NURSING RESPONSIBILITY
PRE-PROCEDURE:
1.Avoid eating or drinking anything other than water for 9-12 hrs before your test
2.Tell physician about your symptoms or any health problems
POST PROCEDURE:
1.Send the specimen to the laboratory

Patient Name: Mr. J.N.G Room: 528

Sex: M Reffering Physician: Dr. Jo-Ann Khow
Age: 71 Years old Date Released: 02/03/2018

RESULT REFERENCE RESULT REFERENCE

Triglycerides 68.14 0.173 0.77 mmol/L 0-1.95
Cholesterol 142.08 mg/dL 0-200 3.68 mmol/L 0.52
64.86mg/dL H 40-60 H 1.68 mmol/L 1.03-
HDL
1.55
VLDL 13.52 H 0-40.00 0.35 mmol/L 0-1.04
98.56 mg/dL 60-159 1.65 mmol/L 1.56-
LDL
4.1
HDLR 2.19 H <40 2.19 <40
84.91 79-115 4.67 mmol/L 4.4-
Glucose (FBS)
6.4

ANALYSIS
HDL is also referred to as the good cholesterol because it helps remove other more harmful forms of cholesterol
from your blood but high HDL result may increased the risk for heart diseas

33
 X-RAY REPORT
DEFINITION: Chest X-Ray is a fast and painless imaging test that uses certain electromagnetic waves to create
pictures of the structure in and around your chesty
NURSING RESPONSIBILITY:
PRE PROCEDURE:
-Before the Chest Xray,you generally undress the patient from waist up and wear on exam gown
-Remove jewelries,eyeglasses,body piercings or other metal.
POST PROCEDURE:
-Send X-ray report

Patient Name: Mr. J.N.G Room: 528

Sex: M Reffering Physician: Dr. Jo-Ann Khow
Age: 71 Years old Date Released: 02/03/2018

FINDINGS:
Streaky densities are seen in the right hilar area
There is slight regression of the previously noted pulmonary congestion
Heart remains enlarged
Diaphragm and costophrenis sulci are well-defined
The rest of the study remains unchanged

ANALYSIS:
Consider right hilar pneumonia
Further slight regression of the pulmonary congestion
Atheromatous aorta
Thoracic osteophytosis

34
 BLOOD CHEMISTRY
DEFINITION: This is to measure levels of important electrolytes and other chemicals.
NURSING RESPONSIBILITY
PRE-PROCEDURE:
1.Explain procedure to the patient
POST PROCEDURE:
1.Send the specimen in the laboratory

Patient Name: Mr. J.N.G Room: 528

Sex: M Reffering Physician: Dr. Jo-Ann Khow
Age: 71 Years old Date Released: 02/03/2018
REFERENCE
TEST RESULT RESULT REFERENCE
RANGE
HBA1C 5.20% 4.30-6.40 5.20% 4.3-6.4

ANALYSIS:
Result is NORMAL

COMPLETE BLOOD COUNT

35
 DEFINITION: Used to evaluate your overall health and detect a wide range of disorder.Measures several
components and features of your blood.The calculation of cellular formed elements of blood in the health status
NURSING RESPONSIBILITY:
PRE POCEDURE:
-Explain the test procedure.explain that slight discomfort may be felt when the skin is punctured
-Encourage to avoid stress if possible because altered physiologic status influences and changes normal
hematologic values
-Apply manual pressure and dressings over puncture site on removal
POST PROCEDURE:
-Check the laboratory results and report any abnormal results
-Instruct to resume normal activities and diet

Patient Name: Mr. J.N.G Room: 528

Sex: M Reffering Physician: Dr. Jo-Ann Khow
Age: 71 Years old Date Released: 02/0/2018
EXAM RESULTS REFERENCE RANGES
Hgb 126 L 140-180 g/L
HCt 0.38 L 0.40-0.54
RBC 4.15 4.0-5.4X10^12/L
WBC 9.0 5.0-10.0X10^9/L
Platelet 64 L 150-400X10^9/L
MCV 91.6 82-92fL
MCH 30.3 26-34
MCHC 330 320-360 g/L
Differencial Count
Segmenters 0.72 0.55-0.70
Lymphocytes 0.23 0.25-0.40
Monocytes 0.04 0.02-0.08
Eosinophils 0.01 0.01-0.06
ANALYSIS:
Low Hemoglobin means that there is no sufficient oxygen transported throughout the body
Low platelet may indicate for possible risk for bleeding; also known as thrombocytopenia
Low haematocrit explains that there is no enough volume in the blood.

ELECTROCARDIOGRAM
DEFINITION:A record or display of a person’s heartbeat produced by electrocardiography
NURSING RESPONSIBILITY

36
PRE-PROCEDURE:
1.Explain procedure to the patient
POST PROCEDURE
1.Read the result

Patient Name: Mr. J.N.G Room: 528

Sex: M Reffering Physician: Dr. Jo-Ann Khow
Age: 71 Years old Date Released: 02/0/2018

INTERPRETATION
Rapid sinus rhythm at 104/min. Normal P-R interval. Left axis
High QRS voltage with ST and T wave changes
The tracing shows sinus tachycardia and left ventricular hypertophy
QRS widening

2 DIMENSIONAL ECHOCARDIOGRAM
DEFINITION: An echocardiogram is a test that uses high frequency sound waves to make pictures of your heart.
NURSING RESPONSIBILITY
37
PRE-PROCEDURE:
1. Expalin procedure to the patient
POST PROCEDURE
1.Wait for result

Patient Name: Mr. J.N.G Room: 528

Sex: M Reffering Physician: Dr. Jo-Ann Khow
Age: 71 Years old Date Released: 02/03/2018

INTERPRETATION
Dilated left ventricular ( normal left ventricular mass index, normal left ventricular relative wall thickness) with global
hypokinesis indicative of coronary artery diseases with depressed left ventricular systolic function
Normal left atrium size with normal left atrial volume index
Normal right atrium , right venricle, main pulmonary artery and aortic root dimensions
Moderate calcific aortic valve stenosis.Thickened aortic valve cusps with no restrictions of motion and scattered
calcification seen at the margins and annulus
Mitral valve sclerosis. Thickened mitral valve leaflets but with no restriction of motion
Structurally normal tricuspid valve and pulmonic valve
No intracardiac mass nor pericardial effusion noted

COLOR DOPPLER:
Trivial mitral regurgitation and tricuspid regurgitation
No stunt anomaly seen
Reversed mitral E/A inflow velocity ratio indicative of grade 1 diastolic dysfunction
Impaired left ventricular relaxation
Normal pulmonary artery pressure
Aortic valve area by continuously equation is 1.1 cm2 with mean valve gradient of 18 mmHg
And peak instantaneous gradient of 32 mmHg

CT-SCAN
DEFINITION: To demonstrate various bodily structures based on their ability to absorb the X-ray beam.
NURSING RESPONSIBILITY
38
PRE-PROCEDURE:
1. Explain procedure to the patient
POST PROCEDURE
1. Wait for result

Patient Name: Mr. J.N.G Room: 528

Sex: M Reffering Physician: Dr. Jo-Ann Khow
Age: 71 Years old Date Released: 02/04/2018
FINDINGS
Comparison with prior plain and contrast cranial CT Scan show faint ill-defined hypodensity at the right fronto-
temporo-parietal region.This is suspicious for an acute right middle cerebral rtery territory infarct.
Dense right middle cerebral artery sign is seen.There is no intracranial haemorrhage, midline shift or
hydrocephalusEvolution of the prior acute left temporo-occipital, left thalamic infarct is seen currently with associated
volume loss
Chronic infarcts within both corona radiate appears unchanged
No significant change in the degree of moderate bilateral chronic
Brainstem and cerebellum are not distorted
Segmental calcifications are seen within both internal carotid and vertebral arteries.
Mucosal thickening is seen within both ethmoid
IMPRESSION:
Findings may relate to evolving acute right middle cerebral artery territory infarct.No evidence of intracranial
haemorrhage, midline shift or hydrocephalus, MR-DWI correlation is suggested
Chronic left temporo-occpital and left thalami infarct with development of gliosis
Unchanged background of small chronic multi-infract disease and moderate degree of white matter ischemic diffuse
atrophy
Atherosclerotic bilateral vertebral and carotid arteries
Bilateral ethmoid sinusitis

BLOOD CHEMISTRY
DEFINITION: This is to measure levels of important electrolytes and other chemicals.
NURSING RESPONSIBILITY
39
PRE-PROCEDURE:
1.Explain procedure to the patient
POST PROCEDURE:
1.Send the specimen in the laboratory

Patient Name: Mr. J.N.G Room: 528

Sex: M Reffering Physician: Dr. Jo-Ann Khow
Age: 71 Years old Date Released:

CONVENTIONAL UNIT S.I UNITS

Test Results Reference Result Reference Range

Potassium 4.00 meq/L 3.6- 5.1 4.0 mmol/L 3.6-5.1

Sodium 137.00 meq/L 136-144 137 mmol/L 136-144

ANALYSIS
Results are NORMAL

IV. MEDICAL MANAGEMENT

a. Treatment
40
Intravenous Therapy
Intravenous fluid regulation is the control of the amount of fluid you receive intravenously, or through your
bloodstream. The fluid is given from a bag connected to an intravenous line. This is a thin tube, often called an IV,
that’s inserted into one of your veins.
Fluids are administered this way for various reasons, all of which require control of the amount given. Without control,
the rate of fluid administration relies on gravity alone. This can result in receiving either too much or too little fluid.
Intravenous infusions are commonly referred to as drips. The intravenous route is the fastest way to deliver fluids and
medications throughout the body.
Purposes:

There are several reasons why you might need to have fluids administered intravenously. For instance, some
treatments rely on IV delivery. These include:
1. rehydration after becoming dehydrated from illness or excessive activity
2. treatment of an infection using antibiotics
3. cancer treatment through chemotherapy drugs
4. management of pain using certain medications

PNSS (Plain Normal Saline Solution)

Type: Isotonic
 Indication: is a sterile, non pyrogenic solution for fluid and electrolyte replenishment in single dose
containers for intravenous administration

DATE/TIME IVF CC/HR Site Remarks

02/2/17-0915H PNSS1L 83 cc/hr Left Cephalic Vein CONSUMED
02/3/17-0350H PNSS1L 42 cc/hr Left Metacarpal Vein CONSUMED
02/4/17-1100H PNSS1L 42 cc/hr Left Metacarpal Vein CONSUMED
02/5/17-0600H PNSS1L 42 cc/hr Left Metacarpal Vein

Oxygen Therapy
Oxygen therapy is a treatment that delivers oxygen gas for you to breathe. You can receive oxygen therapy from
tubes resting in your nose, a face mask, or a tube placed in your trachea, or windpipe. This treatment increases the
amount of oxygen your lungs receive and deliver to your blood. Oxygen therapy may be prescribed for you when you
have a condition that causes your blood oxygen levels to be too low. Low blood oxygen may make you feel short of
breath, tired, or confused, and can damage your body.
Nasal Cannula (2Lpm)
It is the most inexpensive low flow device used to administer O2. It consists of a rubber or plastic
tube that extends around the face, with 0.6-1.3 cm curved prongs that fit into nostrils. One side of the tube connects
to the O2 tubing and O2 supply.
Purpose:
 To deliver a relatively low concentration of O2 when only minimal O2 is required.
 To allow uninterrupted delivery of the O2 while the patient ingest food or fluids.

41
Nursing Responsibilities:
 Check doctor’s order.
 Position, preferably semi-fowlers position if not contraindicated. To enhance lung expansion.
 Open source of oxygen before insertion of Oxygen device. This is to check or malfunctioning the device.
 Regulate the oxygen flow accurately. Excessive administration can cause oxygen narcosis.
 Avoid materials that generate static electricity such as woolen blankets and synthetic fabrics. Use cotton
fabrics blanket.
 Humidify oxygen. Place sterile water into the oxygen humidifier.
 Provide good oronasal hygiene. To prevent dryness and irritations of mucus membrane.
Indication:
Oxygen therapy help reduces the heart's work load of a patient in this case. our patient is diagnosed with BAIAE, a
diseased which the alveoli isn’t functioning well.
Capillary Blood Glucose Monitoring
Blood glucose monitoring is a method of assessing the concentration of glucose in the blood. Tests are performed
rapidly and easily by using a reagent strip (e.g. Glucostix) where a minute drop of capillary blood is obtained from the
client’s digits (finger or toe), earlobe or heel.
Nursing Responsibilities
 Collect together all the equipment including: test meter, test strips, finger pricking device/lancet, clean gauze
and the patient’s records.
 Explain the procedure to the patient and gain verbal consent.
 Ensure the code strip matches the meter code.
 Use lancet device to pierce the skin at the side of the finger and encourage bleeding by use of gravity
 Record the result clearly in nursing notes
 -Report abnormal results, having taken any corrective action within your sphere of competence.
DATE TIME RESULT COVERAGE/TREATMENT
2/2/18 0915H 101
1800H 84
2/3/18 2400H 98
0600H 92
2/3/18 1200H 92
1800H 81
2/4/18 0600H 96
1200H 95
1800H 82
2/5/18 0600H 99
1800H 95
2/6/18 0600H 92

42
 b. Drug Study

Name of Drug92 Route/Dosa Therapeuti Action Contraindicat Adverse Effects Nursing

ge & c use ion Considerati
Frequency ons
Generic Name: 87 Route: It is used Indicated to Active nausea and Assess
Apixaban92 Oral Route to thin the reduce risk pathological vomiting patient for
92 blood so of stroke bleeding headache symptoms
Brand Name: Dosage: that clots and blood in the urine of stroke or
Eliquis 2.5 mg/tab will not systemic shortness of breath peripheral
Classification: form. embolism unusual tiredness vascular
anticoagulants Frequency: It is used associated or weakness disease
BID to treat with periodically
blood nonvalvular during
clots. atrial therapy.
fibrillation

Generic Name: Route: used to Increases Hypersensitiv CNS: fatigue, Assess

Digoxin Oral Route treat atrial force and ity to drug headache apical pulse
fibrillation, velocitiy of CV: Bradycardia regularly for
Brand name: Dosage: a heart myocardial EENT: blurred 1 full
Lanoxin 25 mg/tab rhythm contraction vision minute. If
disorder of and GI: rate is less
Classisifaction: Frequency: the atria prolongs nausea,vomiting than 60
Anti-arryhythmic OD (the upper refractory beats/minut
chambers period of e. Withhold
of the atrioventricu dose and
heart that lar node by notify
allow increasing prescriber
blood to calcium
flow into entri into
the heart). myocardial
cells.

Generic name: Route: used to Has both Hypersensitiv CNS: headache, Instruct
Carvedilol Oral Route treat heart alpha and ity to drug lethargy patient to
failure and beta- Bradycardia, CV: hypotension take drug
Brand name: Dosage: hypertensi adrenergic or heart EENT: hearing loss with food or
Coreg 12 mg/tab on (high blocking block GI: nausea, milk to
blood activity. vomiting reduce GI
Classification: Frequency: pressure). upset
beta adrenergic BID It is also
blocking agent used after
a heart
attack that
has
caused
your heart
not to
pump as
well.

43
Name of Drug Route/Dosa Therapeuti Action Contraindicat Adverse Effects Nursing
ge & c use ion Considerati
Frequency ons
Generic Name: Route: works by Valsartan is Hypersensitiv CNS: dizziness, Monitor
sacubitril and Oral Route increasing an ity to drug or fatigue blood
valsartan the levels angiotensin its CV: hypotension pressure
Dosage: of certain II receptor components EENT: sinus closely,
Brand Name: 500 mg/tab proteins in blocker disorders especially
Entresto the body (sometimes GI: nausea, during initial
Frequency: that can called an vomiting therapy and
Classification: BID dilate ARB). dosage
neprilysin inhibitor (widen) Valsartan adjustments
and an angiotensin blood keeps blood
II receptor vessels. vessels
blocker This helps from
lower narrowing,
blood
pressure Entresto is
by used in
reducing certain
sodium people with
levels. chronic hear
t failure.
This
medicine
helps lower
the risk of
needing to
be
hospitalized
when
symptoms
get worse

Generic Name: Route: This Inhibits Hypersensitiv CNS: headache, Monitor

Spironolactone Oral Route medicatio aldosterone ity to drug drowsiness electrolyte
n is also effects in Acute or GI; vomiting, levels
Brand Name: Dosage: used to distal renal Chronic renal diarrhea (especially
Aldactone 25 mg/tab treat or tubule, insufficiency GU: gynceomastia potassium).
prevent promoting Skin: rash, priuritis Watch for
Classification: Frequency: hypokale sodium and signs and
Aldosterone OD mia (low water symptoms
inhibitor potassium excretion of
levels in and imbalances
the blood). potassium and
retention. metabolic
acidosis

44
Generic Name: Route: removing Empagliflozi Hypersensitiv  Problems Monitor
Jardiance Oral Route excessive n is ity to drug with hematologic
glucose an SGLT2 urination – , kidney,
Brand Name: Dosage: from the inhibitor, a either a and liver
Empagliflozin 10 mg/tab body drug class frequent function test
through which helps urge to results
Classification: Frequency: urine, to stop urinate, or
SGLT2 inhibitors OD Jardiance sodium- little to no
helps to glucose urinating
improve transport  Increased
glycemic proteins likelihood
control that have of urinary
among been tract
patients filtered out infections
with type 2 of the blood  Signs of a
diabetes by the genital
kidneys infection –
being such as
reabsorbed pain,
back into itching or
the blood. a rash

Name of Drug Route/Dosa Therapeuti Action Contraindicat Adverse Effects Nursing

ge & c use ion Considerati
Frequency ons
Brand Name: Route: Soothe Protection Lesions and temporarily Caution the
Bactidol Oral Route and give against oral ulcerations of impaired taste and patient that
temporary bacterial oral/buccal a numb feeling in the solution
Generic Name: relief of and fungal mucosa. the tongue may be too
Hexetidine Frequency: minor sore infection to harsh to
TID throat. give fast taste.
Classification: relief from Assess for
Oral antiseptic sore throat any lesions
and mouth in the mouth
ulcers of the
patient.
Brand Name: Route: used to Decrease Hypersensitiv CNS: headache, Monitor
Triderm Cream Topical treat a inflammatio ity to drug vertigo respiratory
Route variety of n mainly by CV: hypertension status.
Generic Name: skin inhibiting GI: nausea, Watch for
Triamcinolone conditions activities of vomiting worsening
Acetonide Frequency: (e.g., mast cells. signs and
BID eczema, symptoms
Classification dermatitis,
Anti- allergies,
inflammatory(steroi rash).
dal)

45
TOP 5 NURSING DIAGNOSIS

1) Ineffective Cerebral Tissue Perfusion

2) Impaired Physical Mobility

3) Impaired Verbal Communication

4) Urinary Retention

5) Self-care deficit

46
 V. NURSING CARE PLAN

CUES Nursing Diagnosis Rationale Planning Nursing Rationale Evaluation

Intervention
Objective: Ineffective Cerebral Tissue An abnormal Short Term Goal: Independent: After 15-30 minutes
 Facial Asymmetry Perfusion related to accumulation of lipid, After 15-30 minutes of  Assess factors  Assessment will determine of nursing
 Slurred Speech interruption of blood flow as or fatty substances, nursing interventions the and influence the choice of interventions the
related to
( - ) Gag Reflex
 Stuporous evidenced by: and fibrous tissue in patient will be able to: individual situation interventions. Deterioration patient was able to:
GCS = 11/15  Facial Asymmetry the lining of arterial  Increase oxygen for decreased in neurological signs or •Increase oxygen
 Hypoxia  Slurred Speech
 Hgb 126 g/L blood vessel walls. saturation from 96% cerebral perfusion failure to improve after saturation from 96%
( - ) Gag Reflex
(140-180 g/L)  Stuporous These substances to 98% and and potential for initial insult may reflect to 98% and
 Hct 0.39 (0.40- GCS = 11/15 narrow the coronary demonstrate stable increased ICP. decreased intracranial demonstrate stable
 Hypoxia
0.54) vessels in a ways that vital signs. adaptive capacity requiring vital signs.
 Hgb 126 g/L (140-
-O2sat 94% (96-
180 g/L) it reduces blood flow patient to be transferred to -GOAL MET
100%)
 Hct 0.39 (0.40- to the myocardium. Long Term Goal: critical area for monitoring
 Hypovolemia (2D
0.54) After 1-1 1/2 days of of ICP, other therapies. If Long Term Goal:
Echo)
 Hypovolemia (2D
 Cardiac Output: 1.8 Reference: nursing interventions the the stroke is evolving, After 1-1 1/2 days of
Echo)
L/min (4.5 L/min) Medical-Surgical 13 th
patient will be able to: patient can deteriorate nursing interventions
 Cardiac Output: 1.8
 Ejection Fraction:
35% (55%) L/min (4.5 L/min) Edition by  Display no further quickly and require the patient was not
 Stroke Volume:  Ejection Fraction: Brunner&Suddarth’s deterioration or repeated assessment and yet able to display
17 ml (>65ml) 35% (55%)
 Left Ventricular  Stroke Volume: Page: 730 recurrence of deficits. progressive treatment. If no signs of
17 ml (>65ml) the stroke is “completed,” deterioration or
End-Systolic
 Left Ventricular
Dimension the neurological deficit is recurrence of
End-Systolic
(LVESD): 2.9 (1.4- non-progressive, and deficits.
Dimension
47
 2.1 cm/m2) (LVESD): 2.9 (1.4- treatment is geared toward -GOAL NOT MET
 Left Ventricular
2.1 cm/m2) rehabilitation and
End-Diastolic  Left Ventricular
preventing recurrence.
Dimension End-Diastolic  Assesses trends in
 Closely assess
(LVEDD): 3.4 Dimension level of
and monitor
(3.2cm/m2) (LVEDD): 3.4 consciousness
neurological status
 ECG:
(3.2cm/m2) (LOC) and potential
 Sinus Tachycardia frequently and
 ECG: for increased ICP
and Left Ventricular  Sinus Tachycardia compare with
and is useful in
Hypertrophy and Left Ventricular baseline.
 High QRS Voltage determining location,
Hypertrophy
and ST and T wave  High QRS Voltage extent, and
changes and ST and T wave progression of
 CT-Scan: damage. May also
changes
 Evolving Acute
 CT-Scan: reveal presence of
Right Middle  Evolving Acute
TIA, which may warn
Cerebral Artery Right Middle
of impending
Territory Infarct Cerebral Artery
 Chronic Left thrombotic CVA.
Territory Infarct  Fluctuations in
Temporo-Occipital  Chronic Left
 Monitor Vital pressure may occur
and Left Thalami Temporo-Occipital
Signs: because of cerebral
Infarct with and Left Thalami >changes in blood
injury in vasomotor
development of Infarct with pressure, compare
area of the brain.
Gliosis development of BP readings in
 Moderate Degree Hypertension or
Gliosis both arms.
of white matter  Moderate Degree postural hypotension

48
 ischemic diffuse of white matter may have been a
atrophy ischemic diffuse precipitating factor.
 Atherosclerotic
atrophy Hypotension may
bilateral vertebral  Atherosclerotic
occur because of
and carotid arteries bilateral vertebral
shock (circulatory
 X-ray : Cardiomegaly and carotid arteries
 Capillary refill- collapse). Increased
 X-ray :
4 seconds ICP may occur
 V/S Cardiomegaly
 PR= 105bpm  Capillary refill- because of tissue
 RR= 23cpm 4 seconds edema or clot
 BP= 100/60mmHg  V/S
 O2 Sat= 94%  PR= 105bpm formation.
 RR= 23cpm Subclavian artery
 BP= 100/60mmHg
 O2 Sat= 94% blockage may be
revealed by
difference in
pressure readings
between arms.
 Changes in rate,
>Heart rate and
especially
rhythm, assess for
bradycardia, can
murmurs.
occur because of
the brain damage.
Dysrhythmias and
murmurs may reflect
cardiac disease,
49
 which may have
precipitated CVA
> Respirations, (stroke after MI or
noting patterns from valve
and rhythm dysfunction).
 Irregularities can
(periods of apnea
suggest location of
after
cerebral insult or
hyperventilation),
increasing ICP and
Cheyne-Stokes
need for further
respiration.
 Evaluate pupils, intervention,
noting size, shape, including possible
equality, light respiratory support.
 Pupil reactions are
reactivity.
regulated by the
oculomotor (III)
cranial nerve and
are useful in
determining whether
the brain stem is
intact. Pupil size and
equality is
determined by
balance between

50
 parasympathetic
and sympathetic
innervation.
Response to light
reflects combined
 Document function of the optic
changes in vision: (II) and oculomotor
reports of blurred (III) cranial nerves.
 Specific visual
vision, alterations
alterations reflect
in visual field,
area of brain
depth perception.
involved, indicate
 Assess higher safety concerns, and
functions, influence choice of
including speech, interventions.
if patient is alert.  Changes in
cognition and
speech content are
an indicator of
location and degree
of cerebral
involvement and
may indicate
 Position with head
deterioration or

51
 slightly elevated increased ICP.
 Reduces arterial
and in neutral
pressure by
position.
promoting venous
drainage and may
improve cerebral
 Maintain bedrest,
perfusion.
provide quiet and  Continuous
relaxing stimulation or activity
environment, can increase
restrict visitors and intracranial pressure
activities. Cluster (ICP). Absolute rest
nursing and quiet may be
interventions and needed to prevent
provide rest bleeding in the case
periods between of hemorrhage.
care activities.
Limit duration of
procedures.
 Prevent straining
at stool, holding
 Valsalva maneuver
breath.
increases ICP and
potentiates risk of
 Assess for nuchal
bleeding.

52
 rigidity, twitching,  Indicative of
increased meningeal irritation,
restlessness, especially in
irritability, onset of hemorrhage
seizure activity. disorders. Seizures
may reflect
increased ICP or
cerebral injury,
requiring further
evaluation and
 Administer
intervention.
medication as
needed.
>Anti-coagulants

 May be used to
improve cerebral
blood flow and
prevent further
clotting when
> Anti-hypertensives
embolism and/or
thrombosis is the
problem.
 Chronic
hypertension
53
 requires cautious
treatment because
aggressive
management
> Peripheral increases the risk of
vasodilators extension of tissue
damage.
 Transient
hypertension often
occurs during acute
stroke and resolves
often without
therapeutic
intervention. Used to
improve collateral
circulation or
> Stool softeners.
decrease
vasospasm.
 Prevents straining
during bowel
movement and
> Prepare for
corresponding
surgery, as
increase of ICP.
appropriate:  May be necessary to

54
 endarterectomy, resolve situation,
microvascular reduce neurological
bypass, cerebral symptoms of
angioplasty. recurrent stroke.
> Monitor laboratory
studies as indicated:
prothrombin time  Provides information
(PT) and/or activated about drug
partial effectiveness and/or
thromboplastin time therapeutic level.
(aPTT) time, Dilantin
level.

CUES NURSING DIAGNOSIS RATIONALE PLANNING NURSING RATIONALE EVALUATION

INTERVENTIONS

55
 Impaired physical mobility
Objective: related to neuromuscular
-Body weakness impairment as manifested
-Decrease in by body weakness,
range of motion; difficulty Decrease in
turning range of motion; difficulty
-Left sided weakness and turning,
numbness Left sided weakness and
-Left sided hemipharesis numbness,
Left sided hemipharesis
Weakness is a common Short Term Goal: Independent: Short Term Goal:
manifestation of After 8 hours of nursing -Change positions at -Reduces risk of tissue After 8 hours of nursing
neurologic disease. interventions the client least every 2 hours injury. Affected side has interventions the client
Weakness frequently will be able to: supine or side lying and poorer circulation and was able to:
coexists with other - Maintain position of possibly more often if reduced sensation and is - Maintained position of
symptoms of disease and function and skin integrity placed on affected side more predisposed to skin function and skin integrity
can affect a variety of to decrease progression breakdown to decrease progression
muscle, causing a wide of bedsore. -To maintain position of of bedsore.
range of disability. -Support affected body function and reduce risk
Weakness can be parts or joints using of pressure ulcers
sudden and permanent pillows, rolls, foot Goal not met
as in stroke, or supports, gel pads or
progressive, as in many Long Term Goal: foam -Promotes venous return Long Term Goal:
neuromuscular diseases After 1 to ½ days of and helps prevent edema After 1 to 1 ½ days of
such as amyotrophic nursing intervention the -Elevate arm and hand formation nursing interventions the
lateral sclerosis. Any client will be able to: client was able to:
muscle group can be -Maintain or increase -Hard cones decrease - Maintained or increase
affected. strength and function of the stimulation of finger strength and function of
affected and -Place hard hand rolls in flexion, maintaining finger affected and
Reference: compensatory part the palm with fingers and and thumb in a functional compensatory part
Medical-Surgical thumb opposed position
Nursing Book 10 th
Edition, Vol.2 -Maintains functional Goal not met
pp. 1835 position
-Place knee and hip in
extended position -Edematous tissue is
more easily traumatized
-Observe affected side and heals more slowly
for color, edema, or other
signs of compromised
circulation
-Inspect skin regularly, -Pressure points over the
particularly over bony bony prominences are in
prominences. Gently most at risk for
56
massage any reddened decreased perfusion.
areas and provide aids Circulatory stimulation
such as sheepskin pads and padding help prevent
as necessary skin breakdown and
decubitus development

-To promotes circulation

and prevent muscle
Collaborative: atropy
-Collaborate with physical
therapies in providing
range of motion exercise

57
 CUES NURSING RATIONALE PLANNING NURSING RATIONALE EVALUATION
DIAGNOSIS INTERVENTIONS
Impaired verbal Impaired verbal Short Term Goal: Independent: Short Term Goal:
communication related communication is After 8 hours of nursing -Determine the primary -Knowing the client After 8 hours of nursing
Objective: to loss of facial or oral decreased, reduced, interventions the client language spoken primary language and interventions the client
-Facial asymmetry muscle tone control as delayed, or absent to will be able to: fluency in other was able to:
-Muscle and facial manifested by facial receive, process, -Establish method of languages is important to -Established method of
tension asymmetry, muscle and transmit, and use a communication in which Communication communication in which
-Sluggish speech facial tension, sluggish system of symbols needs can be expressed needs can be expressed
speech -Establish rapport with -This helps establish a
the client initiate eye trusting relationship with Goal not met
Reference: contact, shake hands, client or family,
Medical-Surgical address by preferred demonstrating caring
Nursing Book 10 th name and meet family about the client as a
Edition, Vol.2 Long Term Goal: members present, ask person Long Term Goal:
pp. 1836 After 1 to ½ days of simple question, smile After 1 to ½ days of
nursing interventions the and engage in brief nursing interventions the
client will be able to: social conversation if client was able to:
-Participate in appropriate -Participated in
therapeutic therapeutic
communication using -Provide alternative communication using
salience, acceptance, methods of salience, acceptance,
reflecting and active communication: reflecting and active
listening  Provide pad listening
and pencil or
slate board - When the client is able Goal not met
 Use letter or to write but cannot speak
picture board -When the client can’t
write and picture concepts
are understandable to
both parties
 Establish hand -When the client is deaf
and eye signal and reads lips
 Obtain or -If communication is long
standing or the client is
58
 provide access used to this method
to tablet or
computer

Collaboration:
-Refer for appropriate
therapies and support
services -Therapies and other
support groups will obtain
necessary aids for
improving communication

59
 VI. HEALTH TEACHING
Improving Mobility and Preventing Deformities

1. Instruct relatives to position to prevent contractures; use measures to relieve pressure, assist in maintaining
good body alignment, and prevent compressive neuropathies.

2. Instruct relatives to elevate affected arm to prevent edema and fibrosis.

3. Instruct relatives to change patient’s position every 2 hours; place patient in a prone position for 15 to 30
minutes several times a day if indicated

Managing Sensory-Perceptual Difficulties

1. Instruct relative to increase natural or artificial lighting in the room; provide eyeglasses to improve vision.

2. Approach patient with a decreased field of vision on the side where visual perception is intact; place all
visual stimuli on this side.

Assisting with Nutrition

1. Teach the relative/ caregiver how to prepare for GI feedings through a tube if indicated; elevate the
head of bed during feedings, check tube position before feeding, administer feeding slowly, and ensure that
cuff of tracheostomy tube is inflated (if applicable); monitor and report excessive retained or residual
feeding.

Improving Thought Processes

1. Reinforce structured training program using cognitive, perceptual retraining, visual imagery, reality
orientation, and cueing procedures to compensate for losses.

2. Support patient: Observe performance and progress, give positive feedback, convey an attitude of
confidence and hopefulness; provide other interventions as used for improving cognitive function after a
head injury.

3. Have occupational therapist make a home assessment and recommendations to help the patient become
more independent.

4. Coordinate care provided by numerous health care professionals; help family plan aspects of care.

5. Make a referral for home speech therapy. Encourage family involvement. Provide family with practical
instructions to help patient between speech therapy sessions.

6. Encourage family to support patient and give positive reinforcement.

60
61