Biographic Data:

Patient X was admitted on September 21, 2010 at 11:00 pm at

PDMMMC. Patient X who is male, 67 years of age, Married, Roman
Catholic, Filipino is presently residing at Caloocan City.

Nursing Health History:

Chief Complaint:
PTA patient suddenly developed LOC; he then noted weakness of his
left side of the body.

Past illness history:

As verbalized by his wife he have no past history illness. This was the first he
admitted to the hospital.

Family history illness:

Hereditary of both side’s mother and father
(+) hypertension
Present illness history:
Patient was diagnosed (+) Hypertension and (+) DM

Lifestyle:
(+) Smoking (1 ½ pack of cigarettes a day)
(+) drinking (beer twice a day, Moring and evening)
 Gordon’s Functional Health Patterns

Past History Present History

Nutritional-Metabolic - Usual eating pattern - Ostiorized feeding
Pattern “3 meals a day through NGT with low
- Prepares to eat more salt low fat diet.
on vegetables and
high sodium(dried
fish,grilled pork) and
fatty foods(balot,
nilagang
baka,chicaron,crispy
pata)

Elimination Pattern - Has no problem on - With Foley catheter

elimination connected to urine
- Urine output of bag with dark yellow
approximately urine
1,300ml per day output(1,100ml)
- Involuntary passage
of stool characterized
by loose, liquid stool
elimination(150mg)
- Changes diaper 4
times a day
Cognitive-Perceptual - PTA, disoriented to
pattern - Responds time and place
appropriately to - Difficulty of
verbal and physical breathing
stimuli - slurring of speech
- Inability to move
right half/side of the
body
Activity-Exercise - No particular habits -Complete bed rest
pattern of exercise
- Usually consumes 1
½ packs of cigarette
per day
- Drinks regularly 2
bottles of liquor
Sleep-Rest pattern - Irregular sleep when - Fell asleep for 1-2
at home consumes hours
only 5-6 hours of - When awake,
sleep appears agitated and
- Inadequate rest restless due to
administration of
nasal cannula
 Physical Assessment

Normal Findings Actual Findings Remarks

SKIN
Color and Light to deep Pallor Impaired
pigmentation brown Circulation
Hot and Dry
Moisture Moist Fever
The skin slowly
Temperature
The skin springs returns back to its Old Age
Mobility and turgor back to its previous previous state after
state after being being pinched
pinched

NAILS
Nail bed color Pink Pale Impaired
Circulation

Capillary refill capillary refill (1- delayed capillary

3secs) refill (4 secs) Impaired
Circulation

FACE
Skin color Light to deep Pale Impaired
brown Circulation

EYES
Conjunctiva Pink conjunctiva Pale palpebral Decreased tissue
conjunctivae perfusion

MOUTH &
PHARYNX
Lips
Color Pink Pale Poor
Moisture Moist Dry Circulation
Poor Hydration

Tongue
Position Left lateral(slurred Left lateral position abnormal
speech) Slurred speech

Teeth No cavities Some Teeth Poor Oral Care

Missing
(smoker)Some with
cavities
halitosis

NECK
Range of Smooth Restricted Due to Muscle
movements movements movements with Weakness and
without discomfort discomfort numbness
Symmetric and at
Symmetric and at
midline position
midline position

THORAX
Lungs No tenderness Rales, crackles Due to pneumonia
sounds
No adventitious
sound

HEART
Rate Normal(60-100) Abnormal(120bpm) Increased rate due
to Infection

UPPER AND LOWER NORMAL FINDING ACTUAL FINDING REMARKS

EXTREMITIES
SKIN COLOR Light to deep Bluish discoloration Impaired
brown circulation

LABORATORY EXAMINATION
HEMATOLOGY
SEPTEMBER 22, 2010
RESULT REFERENCE REMARKS
HEMATOCRIT 0.37 0.40-0.51 Blood loss
HEMOGLOBIN 131 135-180g/L Blood loss
RBC COUNT 4.11 50-6.5x10-12g/L Blood loss
WBC COUNT 12 4.5-11.0x10g/L Infection
NEUTROPHILS 0.85 0.50-0.70 Infection
LYMPHOCYTES 0.15 0.20-0.40 infection

SEPTEMBER 23, 2010

RESULT REFERENCE REMARKS

WBC 13 4.5-11.0x10g/L Increase WBC
RBC 3.5 50-6.5x10-12g/L Anemia

SEPTEMBER 23, 2010

CHEMISTRY RESULT UNIT REMARKS

SODIUM (ISF) 140.50mmol/L 135-148 Normal
POTASSIUM (IST) 3.36mmol/L 3.50-5.30 Hypokalemia
 HEMOGLUCOSE TEST
SEPTEMBER 22, 2010
6:00PM (before meal)

RESULT REFERENCE REMARKS

129mg/dl 70-110mg/dl Hyperglycemic

SEPTEMBER 27, 2010

12 PM(before meal)

RESULT REFERENCE REMARKS

151mg/dl 70-110mg/dl Hyperglycaemic

LABORATORY EXAM

CHEST X-RAY RESULT:

RIGHT POSTERIOR INFILTRATES PNEUMONIA

SLIGHT LEFT VENTRICULAR CARDIOMEGALY

BONY THORAX IS INTACT

 CT SCAN
ACUTE INTRAPARENCHYMAL HEMATOMA IN THE LEFT BASAL
GANGLIA

MEDICATION

Brand Dosa Action Indication Contraindic Adverse Nursing

Name/Gen ge ation Effect Responsibiliti
eric Name for es
Patie
nt
CEFTRIAXO 2gra Inhibit cell Lower Hypersensitiv Diarrhea, Do not mix
NE ms as wall respiratory e to drug Rash, drugs with
initial synthesis tract eosinophilia, other
Cephalosp
dose promoting infections, nausea, antibiotics.
orin, third
then osmotic due to pain/indurati
generatio
OD (-) instability staphylococcu on
ANST. visually s aureus and tenderness Maintain
bactericidal stertococcus warmth at dosage for at
pnuemonae. injection site least 2 days
after
symptoms
have
disappeared.
 Brand Dosag Action Indication Contraindicat Adverse Nursing
Name/Generic e for ion Effect Responsibiliti
Name Patie es
nt
ATORVASTATIN 80mg / Competitiv Adjunct to diet to Active liver Headache, Give as a
tab ely inhibits decrease elevated disease or Paresthesi single dose
Antihyperlipide
AMG – coA total and LDL unexplained a, anytime with
mic ½ tab
reductase, cholesterol, apo B persistently Asthenia, or without
OD @
AMG – coA this and triglyceride is high LFT’s. Use Insomnia food.
HS.
reductase enzymes primary with grapefruit
nhibitor catalyzes hypercholesterole juice.
the early mia. Determine
rate – lipid levels
limiting within 2-4
step in the weeks.
synthesis of Adjust
cholesterol. dosage
Thus, accordingly.
cholesterol
synthesis is
inhibited or
decreased.

Brand Dosa Action Indication Contraindica Adverse Nursing

Name/Generic ge tion Effect Responsibi
Name for lities
Patie
nt
CLINDAMYCIN 300 Suppresse Serious infection Hypersensitivi CV: If
mg 1 s protein caused by ty to either hypoten significant
Antibiotic,
tab synthesis susceptible clindamycin sion, diarrhea
Lincosamide TID by micro strains of or lincomycin. occurs and
Thromb
organisms streptococci, report to
ophlebit
by binding pneumococci , physician.
is
to stapyloccoci and
ribosomes anaerobic
and bacteria.
preventing
peptide
 bond
formation.
It’s both
bacteriost
atic and
bacterioci
dal.

Brand Dosag Action Indication Contraindicat Advers Nursing

Name/Gene e for ion e Effect Responsibiliti
ric Name Patie es
nt
LOSARTAN 50 Inhibits Antihypertensi Contraindicate CV: No initial
mg / vasoconstricti ve, alone or in d to patient Angina dosage
Anti
tab OD on and combination hypertensive to pectoris, adjustment is
hypertensiv
aldosteron with other drug vasculiti needed for the
e
secreting antihypertensi s. elderly or for
angiotensin
action of ve drugs. those with
II receptor
angiotensine renal
blocker.
to receptor on impairment,
the surface of Reduce risk of including those
vascular stroke in on dialysis.
smooth clients with
muscle of hypertension
other cell and left
ventricular
hypertrophy
 Brand Dosag Action Indicatio Contraindicat Adverse Effect Nursing
Name/Gene e for n ion Responsibiliti
ric Name Patie es
nt
MANNITOL 100 Increases Decrease Anuria, CV: edema, Use a filter
cc / IV the ICP and pulmonary hypo/hypertensi with
Diuretic,
every osmolarity cerebral edema, on, increased concentrated
osmotic
6 of the edema severe heart rate, mannitol
hours glomerula by dehydration, angina like (15%, 20%,
r filtrate, decreasi active chest pain, CHF, and 25%)
which ng brain intracranial Trombophlebiti
Concentratio
decreases mass. bleeding, s
n > 15% may
the except during
To crystallize.
reabsorpti craniotomy,
promote
on of progressive Do not add to
urinary
water and renal damage other IV
excretio
increases following solutions or
n of toxic
excretion mannitol mix with
substanc
of sodium therapy medications
e.
and
chloride.
It also
increases
the
osmolarity
of the
plasma,
which
causes
enhanced
flow of
water
from
tissues
into the
interstitial
fluid and
plasma

Brand Dosage Action Indication Contraindicati Adverse Nursing

Name/Gener for on Effect Responsibili
 ic Name Patient ties
RANITIDINE 50 mg / Competeti Treatment Cirrhosis of the Headache The premixed
IV every vely of liver, impaired infection does
Histamine Abdominal
8 hours inhibits endoscopical renal or hepatic not require
H2 receptor pain
action of ly diagnosd function dilution; give
blocking
histamine erosive Constipation by SLOW IV
drug
on the H2 esophagitis drip over 15 –
at the and for 20 minutes.
receptor maintenanc
sites of e of healing
parietal of erosive Do not
cells esophagitis. introduce
decreasin additives into
g gastric the solution.
acid IV – Prevent
secretion. paclitaxel
hypersensiti Undiluted
vity; reduce ranitidine
the injection
incidence of tends to
GI manifest a
hemorrhage yellow color
associated that may
with stress intensify over
related time without
ulcers adversely
potency

Brand Dosag Action Indication Contraindicat Adverse Nursing

Name/Gene e for ion Effect Responsibiliti
ric Name Patie es
nt
SALBUTAMOL 1 neb Relaxes Prevent/trea Hypersensitivit Precaution: Assess
Anti-asthma every bronchial t y condition
Hyperthyroidi
6 uterine bronchospas before therapy
sm
hours and m in patient and reassess
vascular with DM regularly
smooth reversible Cardiovascula thereafter to
muscle obstructive r disease monitor drug
by airway effectiveness.
stimulati disease. Adverse
ng Beta reaction: Fine
2 tremor of
receptor. skeletal
muscle
 feeling
oftension a
compensary
small increase
in heart rate,
headache,
muscle
cramps

Brand Dosag Action Indicati Contraindicati Adverse Nursing

Name/Generi e for on on Effect Responsibilitie
c Name Patie s
nt
CITICOLINE 1g/ Citicoline is CVD in Parasympath Insomni Somazine
IV an acute etic a, must not be
CNS
every internuerona and hypertonia headach administered
Stimulant
12 l recover e. along with
hours. communicati y medicanents
on enhancer. phase. containing
It increases medophenoxat
the neuro e.
transmission
levels
because it
favors the
synthesis
and
production
speed of
dopamine in
the stratum.

Brand Dosag Action Indicati Contraindicat Advers Nursing

Name/Generic e for on ion e Responsibilities
Name Patie Effect
 nt
Paracetamol 500mg Unknown. Mild pain Hypersensitive Rash Use cautiously in
q4 thought to or fever to drug patient with
(Biogesic)
produce history of chronic
analgesia alcohol use
by bocking because of
pain hepatotoxicity.
impulses
probably by
inhibiting
synthesis of
prostaglandi
n in the CNS
or other at
substance t

REVIEW OF SYSTEM
• Nervous system
1. Brain
-left brain paralysis
← -speech problem
← -blurring of vision
← -level of consciousness(decrease)

2. Nerves
- Damage in the cranial nerves particularly in
Optic Nerves
• Blurred vision
, Trigeminal Nerves
• Numbness of sensation
Facial Nerves
• Loss of motor activity
, Vagus Nerves
Accessory Nerves
• ,
Hypoglossal Nerves
• Slurring of speech

- Loss of sensation in right upper and lower extremities or unilateral or bilateral

part of the body

3. Spinal Cord
-loss of sensation and motor
-loss of homeostasis
-paralysis

• Respiratory System
1. Lungs
- Pneumonia
- Chest pain
- cough with phlegm
- rales or crackles sound
2. Diaphragm
- Difficulty of breathing

• Musculoskeletal System
1. Muscles
-weakness of face muscles
-loss of motor movement
-Weakness of body muscles
2. Bones
-activity intolerance
-immobility
• Circulatory System
• Blood
-blood clot
-increase blood pressure
• Digestive system
• Salivary glands
-difficulty of swallowing/chewing
- Incapable of eating by mouth
 ANATOMY
&
PHYSIOLOGY
←
PATHOPHYSIOLOGY
Sign and
symptoms:
- Flaccid
paralysis
- Spastic
paralysis
- Coma
- LOC
• Frontal:
- Contralateral
muscle
weakness or
paralysis
- Sensory loss in
legs
• Middle
cerebral artery

Complication:
Pneumonia
Aspiration
Constipation
Contractures
related to
paralysis