VELEZ COLLEGE – COLLEGE OF NURSING

F. Ramos St. Cebu City

A Case Study on patient J.T. 63 years old, male, diagnosed with

Cerebrovascular Infarct, Right Thalamic Capsule and
Hypertensive Arteriosclerotic Cardiovascular Disease Not In Failure

Submitted to:

Mark Ebony C. Sumalinog, RN

Submitted by:

2nd years 3rd years

Cavan, Rica Carmela B. Dy, Kelvin 4th years
Clerino, Mark Christian A. King, Erika L. Dolino, Florence
Invento, Charmaine P. Ladera, Shiera Jane Retuya, Anne Gee M
Pedroza, Jan Aira C. Paulo, Alyssa
Romero, Aira Vanissa L. Ruelan, Irish D.
Tan, Samantha Mikaela C. Santos, Al Marion

February 2012

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 INTRODUCTION

Cerebrovascular Infarct
Cerebrovascular Accident

It is the sudden interruption of circulation in one or more of the blood vessels supplying the brain. It is also referred as stroke, or brain attack. It occurs in 2 per 1000 of the general population and
mainly seen in the elderly population. Minor stroke and reversible ischemic neurological deficit (RIND) are used when recovery of clinical features occurs after only 7 days.

Risk Factors:

 Atrial fibrillation or heart murmur

 MI
 Previous stroke or transient ischemic attack (TIA)
 Diabetes Mellitus
 Smoking
 Substance abuse (particularly cocaine)
 Obesity
 Sedentary lifestyle
 Elevated serum cholesterol, lipoprotein, triglyceride, low density lipoprotein (LDL) and high density lipoprotein
 Heavy alcohol use

Non-modifiable risk factors:

 Hereditary/familial tendency
 Old age
 Male
 African American heritage

Types:

1. Ischemic Stroke – caused by occlusion of a cerebral artery either by a:

 Thrombus (thrombotic stroke)
- Commonly associated with the development of atherosclerosis of the blood vessel.
- As the artery becomes completely occluded, the blood flow to the area is markedly diminished.

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 - Decreased blood flow causes transient ischemia, which progresses to complete ischemia, and infarction of the brain tissue.
- Slow onset.
 Emboli (embolic stroke)
- Caused by an embolus or a group of emboli that break off one area of the body and travel to the cerebral arteries via the carotid artery.
- The middle cerebral artery is the most commonly involved.
- As the emboli occlude the vessel, ischemia develops, and the client experiences the clinical manifestations of the stroke.
- Sudden and rapid occurrence.

 Types of Infarction:
Regional cerebral infarction (large vessel) – is caused by an occlusion of main arteries supplying the brain. The most common causes originate outside the brain cavity, predisposed by
atheroma.
Lacunar infarction (small vessel) – is caused by arteriosclerosis of small vessels. It can be clinically asymptomatic or may cause very restricted neurological deficits such as monoparesis.
Cortical laminar necrosis – is caused by generalized failure of perfusion.
Venous infarction – is caused by venous sinus thrombosis. It occurs when there is occlusion of the venous sinuses and cerebral cortical veins by local thrombosis.

2. Hemorrhagic Stroke – vessel integrity is interrupted, and bleeding occurs into the brain tissue or into the spaces surrounding the brain, blood flow to the distal areas of the brain supplied
by the artery is markedly diminished, which leads to cerebral ischemia and infarction and further neurologic dysfunction.

CLINICAL MANIFESTATIONS OF THE VARIOUS CAUSES OF STROKE

Thrombosis Embolism Hemorrhage
a. Tends to develop during sleep or within 1 a. No discernible time pattern, unrelated to a. Typically occurs during active, waking
hour of arising. activity. hours.
b. Ischemia is produced gradually; the b. Clinical manifestations occur rapidly, b. Severe headache and nuchal rigidity
clinical manifestations develop more within 10 to 30 seconds, and often occur.
slowly than those caused by hemorrhage without warning. c. Rapid onset of complete hemiplegia,
or emboli. c. May have rapid improvement. occurs over minutes to 1 hour.
c. Relative preservation of consciousness. d. Relative preservation of consciousness. d. Usually results in extensive, permanent
d. Hypertension. e. Normotension. loss of function with slower, less complete
recovery.
e. Rapid progression to coma.
General Findings of a Stroke:

1. Headache
2. Vomiting

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 3. Seizures
4. Changes in mental status
5. Fever

Specific Deficits after a Stroke:

1. Hemiparesis and hemiplegia

2. Aphasia
3. Dysarthria
4. Dyspahagia
5. Appraxia
6. Hemianopia
7. Agnosia
8. Unilateral Neglect
9. Sensory deficits
10. Behavioral changes

Complications:

 Cerebral hypoxia and decreased blood flow

 Cerebral vasospasm
 Increased ICP
 Hypertension
 Cardiac dysrythmias
 UTI and other complications of mobility

Laboratory Findings:

 PTT
 CT Scan/MRI
 ECG
 Holter monitor test
 Cardiac enzymes evaluation
 Echocardiogram

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Management:

Pharmacologic:

Drug therapy depends on the type of stroke and the resulting neurologic dysfunction.

Goals: to prevent further thrombotic episodes (anticoagulation); increase blood flow to the brain; and protect the neurons (cytoprotection)

Thrombolytic Therapy –dissolves the cerebral artery occlusion; Recombinant tissue plasminogen activator (rt – PA)

Anticoagulants:

1. Sodium heparin and warfarin

2. Antiplatelet Aggregation Medications
3. Antiepileptic drugs, calcium channel blockers, stool softeners, analgesics for pain, antianxiety meds.

Surgical:

For Ischemic Stroke:

 Carotid endarterectomy
- Removal of artherosclerotic plaque or thrombus from the carotid artery to prevent stroke in patients with occlusive disease of the extracranial cerebral arteries.
- Indicated for patients with TIA or mild stroke.
- A surgical prevention of ischemic stroke.
 Carotid stenting
- Used for severe stenosis.

For Hemorrhagic Stroke:

 Surgical mgmt is applied only if hematoma exceeds more than 3 cm in diameter and GCS is decreasing.
 Craniotomy
 Craniectomy

Nursing:

Acute Phase:

1. Maintain patent airway

2. Maintain a BP of 150/100 mmHg to maintain cerebral perfusion

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 3. Suction as prescribed. Never suction nasally and for no longer than 10 seconds to prevent increasing ICP
4. Monitor ICP. Client is at most risk in the first 72 hours ff CVA.
5. Position the client on the side. HOB elevated to 15 to 30 degrees as prescribed.
6. Monitor LOC
7. Maintain fluid and electrolyte imbalance
8. Prepare medications as prescribed e.g., mannitol, thrombolytics

Postacute Phase:

1. Continue implementation from acute phase.

2. Provide skin, mouth and eye care
3. Perform passive ROM exercises to prevent contractures
4. Place antiembolism stockings on client
5. Measure thighs and calves for an increase in size, assess for positive Homan’s sign
6. Monitor gag reflex and ability to swallow
7. Slowly advance diet to foods that are easy to chew and swallow
8. Provide soft and semisoft foods and fluids rather than liquids
9. Position client sitting with the head and neck positioned slightly forward and flexed when eating

Chronic Phase:

1. Approach client from the unaffected side

2. Place client’s personal objects within reach and within visual field
3. Instruct the client with visual problems to turn the head from side to side
4. Increase mobility as tolerated
5. Encourage fluids and high fiber diet
6. Provide gait training

Hypertensive Cardiovascular Disease

Hypertensive Cardiovascular Disease is a medical term for enlargement of the heart.

Hypertensive cardiovascular disease also known as hypertensive heart disease occurs due to the complication of hypertension or high blood pressure. In this condition the workload of the heart is
increased manifold and with time this causes the heart muscles to thicken. The heart continues pumping blood against this increased pressure and over a period of time the left ventricle of the
heart enlarges and this in turn causes the blood pumped by heart to reduce. If proper treatment is not taken at this stage then symptoms of congestive heart failure may be observed.

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Heart failure is more common in people of African American ethnicity, mortality from heart failure is also consistently higher than in white patients, and it develops at an earlier age. The excess of
high blood pressure and its consequences in African Americans is likely to contribute to their shorter life expectancy compared with white Americans.
Classifications of Hypertension (WHO/ISH)*

Category Systolic Diastolic

Optimal <120 <80
Normal <130 <85
High-Normal 130-139 85-89
Grade 1 (Mild hypertension) 140-159 90-99
-subgroup: borderline 140-149 90-94
Grade 2(Moderate hypertension) 160-179 100-109
Grade 3 (Severe hypertension) >or= 180 >or= 110
Isolated Systolic Hypertension (ISH) >or= 140 <90
-subgroup: borderline 140-149 <90
Reproduced with permission. *World Health Organization – International Society of Hypertension, 1999.
Another classification taxonomy described in the literature is presented by the National Institutes of Health (2003):

Category Systolic Diastolic

Optimal <120 <80
Pre-hypertensive 120-139 80-89
Hypertensive >or=140 >or=90
 Stage 1 140-159 90-99
 Stage 2 >or=160 >or=100

Symptoms and signs

The symptoms and signs of hypertensive heart disease will depend on whether or not it is accompanied by heart failure. In the absence of heart failure, hypertension, with or without left
ventricular hypertrophy is usually symptomless. Symptoms of chronic heart failure can include:
 Fatigue
 Cardiomegaly
 Irregular pulse or Palpitations
 Swelling of feet and ankles
 Weight gain
 Nausea
 Shortness of breath
 Difficulty sleeping flat in bed
 Bloating and abdominal pain
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  Greater need to urinate at night
 Altered mentation (in severe cases)
Patients can present acutely with heart failure and pulmonary edema due to sudden failure of pump function of the heart. Acute heart failure can be precipitated by a variety of causes including:
 myocardial ischemia,
 marked increases in blood pressure, or
 cardiac arrhythmias (atrial fibrillation).
Alternatively heart failure can develop insidiously over time.

Causes
High blood pressure increases the pressure in blood vessels. As the heart pumps against this pressure, it must work harder.
Over time, this causes the heart muscle to thicken. The heart must work harder to pump blood out to the body. Without treatment, symptoms of congestive heart failure may develop.
High blood pressure can cause ischemic heart disease because the thicker heart muscle needs an increased supply of oxygen.
High blood pressure also contributes to thickening of the blood vessel walls. This may worsen atherosclerosis (increased cholesterol deposits in the blood vessels). This also increases the risk of
heart attacks and stroke. Hypertensive heart disease is the leading cause of illness and death from high blood pressure.
The heart complications that develop determine the symptoms, diagnosis, treatment, and outlook of hypertensive heart disease.

Possible Complications
 Angina
 Arrhythmias
 Heart attack
 Heart failure
 Stroke
 Sudden death

Gender differences in hypertensive heart disease

There are more women than men with hypertension, and, although men develop hypertension earlier in life, hypertension in women is less well controlled. The consequences of high blood
pressure in women are a major public health problem and hypertension is a more important contributory factor in heart attacks in women than men. Until recently women have been under-
represented in clinical trials in hypertension and heart failure. Nevertheless, there is some evidence that the effectiveness of antihypertensive drugs differs between men and women and that
treatment for heart failure may be less effective in women.
Prevention
 Have your blood pressure checked at regular intervals (as recommended by your health care provider) to monitor the condition. Frequent blood pressure measurements taken at home
are often recommended for people with difficult-to-control high blood pressure.
 Treat your high blood pressure.
 Do not stop or change treatment, except on the advice of your health care provider.
 Carefully control diabetes, hyperlipidemia, and other conditions that increase the risk of heart disease.
In addition to medications, recommended lifestyle changes include:
 Diet changes:

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 o Avoid trans fats and saturated fats
o Increase fruits, vegetables, and low-fat dairy products
o Reduce salt intake (may be beneficial)
o Eat whole grains, poultry, and fish
 Exercise regularly
 Reduce excessive alcohol consumption
 Stop smoking -- cigarettes are a major cause of hypertension-related heart disease
 Lose weight if you are overweight or obese

Differential diagnosis
Other conditions can share features with hypertensive heart disease and need to be considered in the differential diagnosis. For example:
 Coronary artery disease or ischemic heart disease due to atherosclerosis
 Hypertrophic cardiomyopathy
 Left ventricular hypertrophy in athletes
 Congestive heart failure or heart failure with normal ejection fraction due to other causes
 Atrial fibrillation or other disorders of cardiac rhythm due to other causes
 Sleep apnea

Treatment

The primary aim of any treatment in hypertensive cardiovascular disease is reduction of blood pressure and then eventual control of the heart disease. The line of treatment will ordinarily depend
on the condition such as whether there is angina or acute myocardial infarction. The line of treatment may include beta blockers, angiotensin converting enzyme inhibitors (ACE), calcium channel
blockers, diuretics etc depending upon particulars of each individual case. The blood pressure is consistently required to be checked and kept under control in this condition.

NURSING INTERVENTIONS:

 Assess the blood pressure of adults in order to facilitate early detection of hypertension.
 Utilize correct technique, appropriate cuff size and properly maintained/calibrated equipment when assessing clients’ blood pressure
 Educate clients on their target blood pressure and the importance of achieving and maintaining this target.
 Identify lifestyle factors that may influence hypertension management.
 Assess for and educate clients about dietary risk factors as part of management of hypertension, in collaboration with dietitians and other members of the healthcare team.
 Counsel clients with hypertension to consume the DASH Diet (Dietary Approaches to Stop Hypertension), in collaboration with dietitians and other members of the healthcare team.
 Counsel clients with hypertension to limit their dietary intake of sodium to the recommended quantity of 65-100 mmol/day.
 Assess clients’ weight, Body Mass Index (BMI) and waist circumference.
 Advocate that clients with a BMI greater than or equal to 25 and a waist circumference over 102 cm (men) and 88 cm (women) consider weight reduction strategies.
 Counsel clients, in collaboration with the healthcare team, to engage in moderate intensity dynamic exercise to be carried out for 30-60 minutes, 4 to 7 times a week.
 Discuss alcohol consumption with clients and recommend limiting alcohol use, as appropriate to a maximum of:
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 -Two standard drinks per day or 14 drinks per week for men;
- One standard drink per day or 9 drinks per week for women and lighter weight men.

ANATOMY AND PHYSIOLOGY

CENTRAL NERVOUS SYSTEM

The central nervous system (CNS) consists of the brain and spinal cord, which occupy the dorsal body cavity and act as the
integrating and command centers of the nervous system. They interpret incoming sensory information and issue instructions based
on past experience and current conditions. The adult’s brain is about two good fistfuls of pinkish gray tissue, wrinkled like a walnut

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and with the texture of cold oatmeal. It weighs a little over three pounds. Because the brain is the largest and most complex mass of nervous tissue in the body, it is commonly discussed in
four major regions – cerebral hemispheres, diencephalon, brain stem and cerebellum.

Cerebral Hemispheres
The paired cerebral hemispheres, collectively called cerebrum, are the most superior part of the brain and together are good deal larger than the other three brain regions combined. The
entire surface of the cerebral hemispheres exhibits elevated ridges of tissue called gyri separated by shallow grooves called sulci. Less numerous are the deeper grooves called fissures, which
separate large regions of the brain. The cerebral hemispheres are separated by single deep fissure, the longitudinal fissure. Each cerebral hemisphere has three basic regions: a superficial
cortex of gray matter, which looks gray in fresh brain tissue; an internal white matter; and the basal nuclei, islands of gray matter situated deep within the white matter.
(1) Cerebral Cortex - Speech, memory, logical and emotional response, as well as consciousness, interpretation of sensation, and voluntary movement are all functions of the neurons of the
cerebral cortex.
(2) Cerebral White Matter
It is composed of fiber tracts carrying im impulses to, from, or within the cortex. One very large fiber tract, the corpus callosum, connects the cerebral hemispheres. Such fiber tracts are
called commisures. The corpus callosum arches above the structures of the brain stem and allows the cerebral hemispheres to communicate with one another.
(3) Basal Nuclei
Basal nuclei are several “islands” of gray matter, buried deep within the white matter of the cerebral hemispheres. It helps regulate voluntary motor activities by modifying instructions
(particularly in relation to starting or stopping movement) sent to the skeletal muscles by the primary motor cortex.

Diencephalon
It is also called the interbrain, which sits atop the brain stem and is enclosed by the cerebral hemispheres. The major structures of the diencephalon are the thalamus, hypothalamus, and
epithalamus. The thalamus is a large, dual lobed mass of grey matter buried under the cerebral cortex. It is involved in sensory perception and regulation of motor functions. The thalamus is
a limbic system structure and it connects areas of the cerebral cortex that are involved in sensory perception and movement with other parts of the brain and spinal cord that also have a role
in sensation and movement. As a regulator of sensory information, the thalamus also controls sleep and awake states of consciousness.The thalamus is involved in several functions of the
body including: motor control, receives auditory, somatosensory and visual sensory signals, relays sensory signals to the cerebral cortex and controls sleep and awake states. Directionally, the
thalamus is situated at the top of the brainstem, between the cerebral cortex and midbrain. It is superior to the hypothalamus. The hypothalamus makes up the floor of the diencephalon. It
plays an important role in the regulation of body temperature, water balance and metabolism. It is also a part of the limbic system or the “emotional visceral brain” which is the center for
thirst, appetite, sex, pain, and other pleasures. The mammillary bodies, reflex centers involved in olfaction (the sense of smell), bulge from the floor of the hypothalamus posterior to the
pituitary gland. The epithalamus which forms the roof of the third ventricle has two important parts: the pineal body (part of the endocrine system) and the choroid plexus, knots of
capillaries within each ventricle, form the cerebrospinal fluid.

Brain Stem
The brain stem is about the size of the thumb in diameter and approximately 3 inches long. It provides a pathway for ascending and descending tracts which composed of many small,
gray matter areas. Its structures are the midbrain, pons and medulla oblongata. The midbrain extends from the mammillary bodies to the pons inferiorly. The cerebral aqueduct is a tiny canal
that travels through the midbrain and connects the third ventricle of the diencephalon to the fourth ventricle below. The cerebral peduncles convey ascending and descending impulses while
the corpora quadrigemina are protrusions or reflex centers involved with vision and hearing. The pons is rounded structures made of fiber tracts that involve in control of breathing. The
medulla oblongata which is the most inferior part contains centers that control heart rate, blood pressure, breathing, swallowing, and vomiting.

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Cerebellum
The large, cauliflower-like cerebellum projects dorsally from under the occipital lobe of the cerebrum. It provides the precise timing for skeletal
muscle activity and controls our balance and equilibrium. The cerebellum can be compared to an automatic pilot, continuously comparing the brain’s
“intentions” with actual body performance by monitoring body position and amount of tension in various body parts.

Cerebral Circulationrefers to the movement of blood through the network of blood vessels supplying the brain. The arteries deliver oxygenated blood,
glucose and other nutrients to the brain and the veins carry deoxygenated blood back to the heart, removing carbon dioxide, lactic acid, and other
metabolic products. Since the brain is very vulnerable to compromises in its blood supply, the cerebral circulatory system has many safeguards. Failure
of these safeguards results in cerebrovascular accidents, commonly known as strokes. The amount of blood that the cerebral circulation carries is
known as cerebral blood flow. The presence of gravitational fields or accelerations also determine variations in the movement and distribution of
blood in the brain, such as when suspended upside-down.There are two main pairs of arteries that supply the cerebral arteries and the cerebellum:

Internal carotid arteries: These large arteries are the left and right branches of the common carotid arteries in the neck which enter the skull, as
opposed to the external carotid branches which supply the facial tissues. The internal carotid artery branches into the anterior cerebral artery and
continues to form the middle cerebral artery
Vertebral arteries: These smaller arteries branch from the subclavian arteries which primarily supply the shoulders, lateral chest and arms. Within
the cranium the two vertebral arteries fuse into the basilar artery, which supplies the midbrain, cerebellum, and usually branches into the posterior
cerebral artery.

Both internal carotid arteries, within and along the floor of the cerebral vault, are interconnected via the anterior communicating artery. Additionally,
both internal carotid arteries are interconnected with the basilar artery via bilateral posterior communicating arteries.

The Circle of Willis, long considered to be an important anatomic vascular formation, provides backup circulation to the brain. In case one of the supply
arteries is occluded, the Circle of Willis provides interconnections between the internal carotid arteries and basilar artery along the floor of the
cerebral vault, providing blood to tissues that would otherwise become ischemic.

Intracranial pressure (ICP) is the pressure inside the skull and thus in the brain tissue and cerebrospinal fluid (CSF). The body has various mechanisms by which it keeps the ICP stable, with CSF
pressures varying by about 1 mmHg in normal adults through shifts in production and absorption of CSF. CSF pressure has been shown to be influenced by abrupt changes in intrathoracic
pressure during coughing (intraabdominal pressure), valsalva (Queckenstedt's maneuver), and communication with the vasculature (venous and arterial systems). ICP is measured in
millimeters of mercury (mmHg) and, at rest, is normally 7–15 mmHg for a supine adult, and becomes negative (averaging −10 mmHg) in the vertical position.[1] Changes in ICP are attributed
to volume changes in one or more of the constituents contained in the cranium.

Protection of the Central Nervous System

Meninges
The three connective tissue membranes covering and protecting the CNS structures are meninges. The outermost layer, dura mater meaning “tough or hard mother” is a double layered
membrane which surrounds the brain. The inner dural membrane extends inward to form a fold that attaches the brain to the cranial cavity. The middle meningeal layer is the weblike
arachnoid mater that looks like a cobweb. Its threadlike extensions span the subarachnoid space to attach it to the innermost membrane, the pia mater or “gentle mother”.
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 Cerebrospinal Fluid
The CSF is a watery “broth” similar in its makeup to blood plasma, from which it forms. The CSF in and around the brain and cord forms a watery cushion that protects the fragile nervous
system from blows and other trauma. Inside the brain, CSF is continually circulating from the two lateral ventricles (in the cerebral hemispheres) into the third ventricle (in the diencephalon),
and then through the cerebral aqueduct of the midbrain into the fourth ventricle dorsal to the pons and medulla oblongata. Some of the fluid reaching the fourth ventricle simply continues
down into the spinal cord, but most of it into the subarachnoid space through three openings in the walls of the fourth ventricle.
The Blood – Brain Barrier
The blood-brain barrier is made of capillaries which separates the neurons from the bloodborne substances. Metabolic wastes such as urea, toxins, proteins, and most drugs are
prevented from entering the brain tissue. Nonessential amino acids and potassium ions not only are prevented from entering the brain, but also are actively pumped from the brain into the
blood across capillary walls.

Spinal Cord
The cylindrical spinal cord, which is approximately 17 inches long, is a glistening white continuation of the brain stem. Enclosed within the vertebral column, the spinal cord extends from
the foramen magnum of the skull to the first or second lumbar vertebra, where it ends just below the ribs. In humans, 31 pairs of spinal nerves arise from the cord and exit from the vertebral
column to serve the body area close by. The collection of spinal nerves at the inferior end of the vertebral canal is called the caudaequina it looks so much like a horse’s tail. The gray matter
of the spinal cord looks like a butterfly or the letter H in cross section. It surrounds the central canal of the cord, which contains CSF.

CARDIOVASCULAR SYSTEM
Anatomy of the Heart:
- Mediastinum
= between 2 lungs; size of the fist
= positioned so the apex is directed towards the left hip while the base is pointing to the right shoulder
*apex – 5th intercostal space
*base – 2nd intercostal space
= double layered serous membrane

- pericardium
Inner – visceral pericardium – attached to the heart’s surface
Outer – parietal epicardium
Parietal – dense connective tissue & connects the heart with the surrounding structures.

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 *the double layer serous membrane if a serous fluid for lubrication (so no friction when pumping heart action)
*Pericarditis – the inflammation of the pericardium due to infection.
= constricts /restricts the movement of the heart.
*Pericardial Rough

Three Layers:
1. Endocardium – thin layer if connective tissue line by endothelium (simple squamous)
2. Myocardium – thickest layer made of cardiac muscle and dense connective tissue (cardiac skeleton)
to support
3. Epicardium – thin layer of CT lined by mesothelium

Chambers of the Heart

- both atria = divided by interatrial septum
- both ventricles – divided by interventricular septum
Right – Pulmonary Circulation
Vena Cava → RA → Tricuspid Valve → RV→ Pulmonary Artery → Lungs → Pulmonary Veins → LA
Left – Systemic Circulation
Pulmonary veins → LA → Mitral (Bicuspid) Valve →LV → aorta → numerous branches →Body

Valves:
2 Atrioventricular Valves:
Bicuspid /Mitral Valve = 2 flaps; left AV valve
Tricuspid Valve = right AV valve; 3 flaps
Chordae Tendineae – tiny white chords that anchor 3 edges of cusps to the walls of the ventricles.
Semilunar Valves - 3 cusps
- aortic and pulmonary valves
- no chordae tendineae

Homeostatic Imbalance:
1). Valvular Stenosis – valves get stiff due to repeated infection.
2). Incompetent Valve – valve doesn’t close properly sot there is a backflowof blood; incomplete in work load of the heart.

Cardiac Circulation
- supplied by the coronary arteries
- coronary artery arise from the aorta (ascending part of the aorta) → atrioventricular groove intracardia braches blood coming from the heart → drained by cardiac veins → empty into coronary
sinus (post part of the heart) → RA.
* Myocardial Infarction – inadequate blood flow of the valve due to narrowing of artery causing acute chest pain.
* Ischemia – deprived of o2 for longer period.
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 Conduction:
- Cardiac muscle in contrast with other muscles are different. If contracts independently, it can be controlled by:

1. Autonomic Nervous System - ↑ or ↓ heart rate

↑ - sympathetic (tachycardia)
↓ - parasympathetic (bradycardia)
2. Intrinsic Conduction System (ICS) / Nodal system
- specialized cardiac muscle cell
Main function: ensure cardiac muscles depolarization occurs only in one direction (atria to ventricle) and to regulate the contraction rate of the heart.
Components of ICS:
1. Sinoatrial Node
- posterior wall of RA
- fastest rate of depolarization and therefore dictates the rate of contraction of the entire heart.
2. AV Node / Atrioventricular Node
- found at the atrioventricular junction
- conducts depolarization from SA node to Bundles
- delay depolarization so that atria can contract completely before ventricles can contract.
AV Bundles – upper part of the AV septum.
Bundle of His – 2 branches: Bundle Branches
- formed at the lower part of the AV septum

Purkinje fibers – bundles – myocardium

Heart Block
- damage to the AV node or anywhere from there to the bundle branches.
- may be partial or total
Total – release ventricles from control of SA node
- localized contraction in some areas.

Fibrillation
- major cause of deaths in heart attack.
- 40 – 50% of deaths.

Cardiac Cycle of the Heart

- comprises the count of 1 complete heart beat during which both atria & ventricles contracts and relaxes.

Events in the Cycle:

1. Middle – Late Diastole
- the heart us completely relaxed; intraventricular pressure is low.
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 - blood is coming from the vena cava flows to the heart
- semilunar valves are closed
- AV valves are open
- end of this phase: atria contracts & force blood to go to the ventricles.

2. Ventricular Systole
- Ventricles now contract; pressure inside is ↑; IV pressure rise, semilunar valves are open , AV valves are closed; blood is rapidly injected to aorta & pulmonary artery.
3. Early Diastole
- when the ventricles start to relax; semi lunar valves close; ventricular pressure drops; blood flows from aorta to ventricles.

Heart Sounds
1. Lub - longer, low pitched.
- closing of the AV valves
2. Dup / Dubb - shorter / high pitched
- closure of semi lunar valves

Incompetent Heart Valve – causes swishing sound due to the backflow of blood.

Valvular Stenosis - turbulence of blood flow to produce harsh sounds.

Cardiac Output
- the amount if blood pumped out by each ventricle in one minute and is a product of the heart rate and stroke volume.

Starling’s Law
- Force of contraction is the function of the length of cardiac muscle at the end of diastole.
*most important factor that stretches cardiac muscle is venous return
* heart rate also influences venous return

Heart Rate Regulation

- function of ANS (autonomic nervous system) is very important.
Sympathetic stimulation - ↑ heart rate
Ex. Exercising, stress (physical, emotional), ↑ in temp. , hormones (thyroxine & epinephrine)
Parasympathetic stimulation - ↓ heart rate
Homeostatic Imbalance
1). Congested Heart Failure
- deficiency of the heart as the pump is diminished resulting to insufficient blood flow to body tissues
- progressive condition reflecting weakening of the heart
Common Cause: myocardial infarction
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 Hypertension
Valvular deficit (stenosis or deficiency)
2). Pulmonary Congestion
- occurs in left heart failure
- left heart fails to pump blood in systemic circulation blood will be dumped back to the lungs (pulmonary congestion)
3). Systemic Congestion
- right heart failure
- right heart not capable of pumping forward = dumped back to systemic veins
- fluid escapes into interstitial spaces (areolar tissues) resulting to edema
Vascular System - closed transport system where blood circulates inside BV
LV → aorta → smaller arteries → capillaries → venules

Microscopic Anatomy:
Blood Vessels: 3 layers:
1). Tunica Intima (Interna)
- composed of thin layer of CT covered by endothelium (simple squamous)
2). Tunica Media
- thick layers made up of alternating smooth muscles & elastic fibers.
* in large arteries, more elastic fibers than smooth muscle so that they can expand to absorb pressure; enables blood to be pumped continuously.
*middle/small arteries, more smooth muscles than elastic fibers
- under influence of sympathetic
3). Tunica Adventitia (Tunica Externa)
- made up of CT
- = to support & protect the BV from injury
Differences:
Arteries – have smaller lumen than veins
- have thicker walls than veins bec of pressure
- have well demarked layers
- have tunica media as the thickest layer
Veins have tunica adventitia as thickest
Arteries have no valves except for the great vessels
Capillaries:
- thin walled minute vessels composed only of endothelium & its basement membrane.
Flow of Blood from arteriole to venule passes through a capillary bed / microcirculation
Microcirculation – composed of vascular shunt = vessel connecting arteriole directly to venule
True capillaries – possess precapillary sphincter at their proximal ends.
Homeostatic Imbalance:
17
1). Varicose Veins
- Cause: pulling of blood in your vein
- insufficient valves
2). Thrombophlebitis
- undesirable intravascular clotting caused by a roughening of a venous lining.

Arteries of the Brain:

* entire CNS (central nervous system) is supplied by 2 major vessels:
1. internal carotid
2. vertebral artery
Internal Carotid – comes from common carotid
- run through the neck, enter the skull through the temporal bone
- divide into anterior & middle cerebral arteries that supply most of lateral & medial surfaces of cerebral hemisphere.

Vertebral Artery - arise from subclavian artery

- would unite to form basilar artery which supplies the brainstem & cerebellum.

Basilar Artery – into posterior cerebral artery that supply occipital lobe & inferior surface of the brain

Circle of Willis – provides collateral / alternate circulation when the other arteries are blocked

Arteries that contribute to the Circle of Willis:

1. Anterior Cerebral Artery

2. Anterior Communicating Artery
3. Internal Carotid Artery
4. Posterior Communicating Artery
5. Posterior Cerebral Artery
Hepatic Portal Circulation:

Portal Circulation – special circulation wherein a portal vessel receives blood from a set of capillaries & passes the blood to another set of capillaries before blood is returned to the systemic circulation.
* in the liver, it is the portal vein – that receives blood from capillaries of the digestive tract through several veins & pass blood to sinusoids in the liver before blood will be drained in the hepatic vein.
Portal Circulation allows nutrients absorbed from the digestive tract to pass through liver for processing before blood is passed on to the systemic circulation.

Veins that drain into portal circulation:

1. Inferior Mesenteric Vein - drains second half of the large intestine
2. Splenic Vein – drains spleen, pancreas & left half of the stomach
18
3. Superior Mesenteric Vein – drains the small intestine & first part of the colon
4. Left Gastric Vein – drains the right side of the stomach

Fetal Circulation:
- because some parts of the fetus is not physiologically functioning yet.
* nutrients, O2 & excretion of waste products are done in the placenta since the lungs & the digestive organs of the fetus are not functioning.
Blood From Placenta
↓
Umbilical vein
↓
Ductus Venosus
↓
Inferior Vena Cava
↓
Right Heart
↓
Left Heart
↓
Aorta
↓
Umbilical Artery
↓
Placenta
* umbilical artery – towards the mother
* umbilical vein – towards the baby
Vessels that shunt blood:

1. Ductus Venosus – bypass the liver

2. Foramen Ovale – flap like opening in the interatrial septum (of the heart)
- bypass the lungs & shunt blood from the right atrium to the left atrium
3. Ductus Arteriosus – shunt vessel connecting the pulmonary trunk to the aorta
- shunt blood from the pulmonary trunk to aorta bypassing the lungs.

Physiology of Circulation:
Arterial pulse – pressure wave created by each ventricular contraction due to the expansion & ↓ recoil
of the arteries.
Pulse rate = heart rate
19
Pulse – easily palpated in some parts of the body.

Blood Pressure – pressure exerted by blood against the walls of the blood vessel
- force that keeps blood circulating continuously between heart beats.
- highest in large arteries & continue to drop as arteries become smaller.

Mechanisms:
1. Pressure of valves to prevent backflow
2. Milking action of muscles during contraction
3. Negative pressure of thoracic cavity through inhalation

Measuring BP
- palpatory or auscultatory method
Measure & Parts:
1. systole – measures the pressure at peak of ventricular contraction
diastole – measure pressure when ventricles are relaxed.

Major Factors Affecting BP

1. Cardiac Output (CO) - ↓CO = ↓ BP
2. Peripheral Resistance - amount of friction encountered by blood as it flows through the blood vessels
- determined by constriction of the BV
3. Viscosity of Blood - the thickness or stickiness of the blood.
Factors Influencing Pulse Rate:
1. Neural Factors – referring to ANS
Parasympathetic – no effect
Sympathetic – cause vasoconstriction
*vasoconstriction may occur:
1. low blood volume – needs to increase pressure
2. exercise

2. Renal Factor
- low blood volume – poor circulation
- increase blood volume
Renin angiotensin mechanism:
- low sodium – low blood volume
- secrete rennin
- angiotensin becomes active
- vasoconstriction
20
 Aldosterone Mechanism:
- reabsorbs sodium ions from kidney tubules
- reabsorbs water
- increase volume

3. Temperature
- can alter BV: vasoconstriction – cold
Vasodilation – hot

4. Chemical
- epinephrine – neurotransmitter on
Sympathetic
- causes vasoconstriction
- nicotine - causes vasoconstriction

5. Diet
Homeostatic Imbalance:
1). Hypertension – 140/90
- sustained / successive
- 90% essential HPN
Most common cause: atherosclerosis – is the formation of plaques (cholesterol, lipids, etc.)
Arteriosclerosis – hardening of the arterial wall

2). Hypotension – lower BP

Acute hypotension – due to blood loss
Chronic hypotension – due to poor nutrition
Orthostatic hypotension – related to posture

Capillary Exchange:
- allows passage of gases & substances
- move along concentration gradient

How Substances Pass Through:

1. Diffuse directly across membrane because they are lipid soluble (gases)
2. If lipid-soluble, pass by endocytosis or exocytosis (active transport)
3. They may pass through intercellular cleft not joined by tight membrane
21
4. Pass through openings that are covered with thin membranes as in fenestrated arteries
Examples: skin capillaries, endocrine glands, renal glomerulus

Forces that operate capillary functions:

1. Hydrostatic pressure – pressure that forces fluids/solutes out of the BV due to BP
2. Osmotic pressure – pressure that tend to drain both fluid into the bloodstream
* net difference of 2 pressures determine movement of solution.

CLIENT IN CONTEXT PRESENT STATE INTERVENTIONS EVALUATION

J.T, 63, Male, Filipino, Roman Catholic,
Married from Conslacion Cebu, was admitted
for the first time last February 4, 2012 due to
left sided hemiparesis. He was accompanied
by his wife and son via taxi. Patient was
admitted under the services of Dr. Espanol
with a case number and hospital number of
12-14973/5293.
History of present illness
Night PTA, patient was walking toward his
shop when he noted left sided weakness but
still able to stand and walk and left arm
weakness also noted associated with
headache and nausea. Blood pressure was
taken by his daughter which revealed 140/100
mmHg. No medications taken. No consult
done. Tolerated condition.
Morning PTA, upon waking up, patient was
unable to stand and bear his weight , nausea
and left sided weakness worsened, this
prompted the patient for admission.
PHYSICAL EXAMINATION
DAY 1 February 9, 2012 3:00 pm
General Appearance: Examined awake,
conscious, responsive, coherent, eupneic and
afebrile; with the vital signs:BP: 130/90 mmhg
PR: 72 cpm RR: 18 T: 37 degrees Celsius/axilla
Height: 5’4
Weight: 45Kg
BMI: 19.68
SKIN:
Evenly colored brown without unusual
discoloration, skin is intact and there is no
reddened areas, smooth without lesions, and
even, noted a small horse shoe-like tattoo at left
arm, warm to touch, easily pinched and
immediately returns back to its original position
(good skin turgor), skin rebounds and does not
remain indented when pressure is release
2-4-12 11am
 Pls admit in the department of Internal
Medicine under the service of Dr. Español
 TPR q 4hrs
 Pls secure consent to care
 Pull
 Problem: 1 left sided hemiparesis
 Labs: CBC, Creatinine, RT, APA, Na, K, 12
lead ECG, CXR- MSCC, Lipid panel, CT scan
brain plain
 Venoclysis with PNSS 1L at 15gtts/min
 Medication
1. Citicoline 1gm IVTT q6H 1st dose now
2. Atorvastatin 80mg/tab 1 tab OD qHS
3. Captopril 25mg/tab 1 tab q6h PO PRN
for SBP≥180 mmHg
4. Senokot Forte II tabs OD qHs
 I & O q4hrs, chart on absolute figures
 Monitor V/s q2, to include neurologic V/S,
refer accordingly
 Dr. español informed
3pm

22

Past health history
Patient is not a known hypertensive, non-
diabetic, and non asthmatic. HFD includes
Cancer on paternal side.
Previous Hospitalizations include:
1988 sto nino clinic : due to “pasmo” as
claimed by patient. Unrecalled medications
were given.
He was also hospitalized due to diarrhea but
unrecalled date.
Gordon’s Functional Health Pattern
1. Health Perception and Health
Management Pattern
Patient describes health as important by
verbalizing “ Importante jud ang health day
dapat jud di masakit”. Patient rated his health
as 9/10 with 10 as the highest and 1 is the
lowest. Patient verbalizes “ 90% jud akung
rating sa akung health before ko na ospital
dae wa gud koi mga sakit2x”. Now, his
present condition is his immediate concern.
He shared that before hospitalization, his daily
activities was not affected by his illness. His
major influencing factors in health
management and adherence in behaviour
were friends and children. He shared that he
only sought medical check up when
something is wrong and when his condition is
at worst already. He claimed that whenever
he feels sick or any discomfort like headache,
fever and colds, he only treats himself with
water therapy and rest.
He also claimed that he does not believe
SCALP & HAIR:
Black to grayish hair (natural), scalp is clean and
dry, hair is smooth, without lesions or lice
infestation
NAILS:
Clean, transparent, and well-trimmed nails with
light pink nail bed; has 160-degree angle
between the nail base and the skin, hard and
immobile, smooth and firm, nail plate firmly
attached to nail bed, CRT<2sec (2 secs)
HEAD & FACE:
Symmetric, round, erect & in midline; hard and
smooth without lesions or lumps. Head is
upright; no abnormal facial movements noted,
no swelling, tenderness, or crepitation with
movement.
EYES & VISION:
Eyeballs are symmetrically aligned in sockets
without protruding or sinking.
Eyebrows are black, same with hair color,
symmetric and evenly distributed.
Eyelids: Lashes evenly spaced and curled
outward.
Bulbar conjunctivae and sclera clear, moist,
smooth with tiny vessels visible; sclera are white
Palpebral conjunctivae pink, moist, and free of
swelling, lesions, and abnormal discharges.
Cornea &lens: transparent, moist and without
opacities; lens are clear
Iris is round; uniform in color
Pupils are equally round; illuminated pupil
constrict and pupil opposite the one illuminated
constricts simultaneously; pupils converge and
constrict as object moves in toward nose; pupil
 IVFTF with PNSS IL at 15 gtts/min
 Include SGPT to lab
 Give 1st dose of Lipitor 80mg 1 tablet now
 ASA 80mg 2 tablets now then 1 tab OD per
lunch
 Hold Senokot of BM ≥ 2x/g
 Ranitidine 150mg 1tab now 1 tab BID PO
 2D echo & carotid Doppler scan
7:15
 IVFTF with PNSS IL @ 15gtts/min
2-5-12 7am
 IVFTF with PNSS IL @ 15gtts/min
11am
 For HBA1c determination and uric acid
 Revise diet to full low salt, low fat, low
cholesterol diet
1:15
 Additional dietary specifications diabetic
diet 2100 kcal day (CHO 315g, CHON 105g
rest in fats, no smoke) in 3 meals and 2
snacks
2-6-12 8:05
 Additional dieatary specifications: low
purine diet
 Allopurinol 300mg/tab 1 tab OD PO PC
breakfast
 Repeat CBC, serum crea, Na+, k+, in am
(Feb. 7
 Hold Allupurinol
 For dietary fat. Low purine diet
 May have wheelchair ride
3pm
 d/c Senokot
8:45
 IVFTF with PNSS 1L @ 15gtts/min
9:10
 Facilitate dietary instruction pls
23
in any quack doctors but consume herbal
medicines like "wachichao" for leg pains. He
also claimed that he does not know the
correct way on how to perform Testicular Self
Examination but does do it in his own way.
Patient claimed that he was immunized
completely when he was a child. He had his
last dental examination last September 2012
and was advised to replace his teeth with
dentures.
During hospitalization, patient rated his
health as 5/10. Patient verbalizes that “ 50/50
nlng karun dae kay tungud ani akung
condition karun”. Patient has a family history
of Cancer. Patient is a smoker consuming 10-
12 sticks per day for 45 years. Patient is an
occasional beverage drinker consuming 6
bottles of pilsen every occassion.
Environmental History
Work Environment
Patient is a consultant of Gungob home
industries. He works 4 hours a day 7 times a
week. He also extends his time of work. His
work environment is not exposed to any
chemicals and radiations. He did not
experience work related accidents or injuries.
He is satisfied with his job since his income is
enough to provide the needs of his family.
Home environment
Patient is living with his family in a
one storey house owned by the family for 43
years. They are 7 in the house including their
helper. Their house is made up of mixed
materials and is in good condition. There are 5
windows, 5 doors and 4 bedrooms. Their
kitchen, living room and dining room doesn’t
responses uniform. 2-7-12
Corneal light reflex: reflections of light noted at  Refer to Dr. Anota
same location on both eyes  May sit up and dangle legs
Cover test: uncovered eye remains fixed; 4pm
covered eye does not move as cover is removed.  Thank you for the referral
Cardinal gaze: both eyes move in the same  Dr. E. Anota informed
direction in a coordinated manner in all six  Attach official result of carotid Doppler
directions studies to chart
Color vision: able to identify colors in 7:10
surroundings  IVFTF with PNSS 1L @ 15gtts/min
Visual acuity: Near vision: not able to read 2-8-12 2:30pm
student nurse’s nameplate with a distance of 3  To consume stocks of Citicoline IV then
feet OD and OS without hesitation and squinting; shift to Citicoline 5ml TID PO PC
Peripheral vision: client sees examiner’s finger at 2-812
the same time the examiner sees it  Thank you for the referral
 Patient seen
EARS AND HEARING:  Rehab good
Ears are symmetric, earlobes are soldered.  Start physical therapy
External ear smooth, without lesions, lumps, or  Monitor v/s
nodules; color consistent with facial color; no 2-9-12 @ 7:30
discharge present; non-tender auricle and  Shifted present IVF to heplock once
mastoid process; repeats whispered two syllable consumed
word (VELEZ) at 3 feet distance. 2-11—12 @ 9:30 am
 Repeat CBC, serum, creatinine, Na+ , K+ in
NOSE AND SINUSES: am (Feb. 12)
External portion consistent with the rest of the 3:25pm
face; smooth and symmetric; no tenderness  Defer repeat labs
noted  May go home
Client able to sniff and blow through each nostril  Home medications:
while other is occluded 1. Citicoline 5ml TID PO PC
Nasal mucosa is dark, pink, moist, and free of 2. Aspirin 80mg/tab a tab OD PO pc
exudates; nasal septum at midline; intact and lunch
free of ulcers 3. Atorvastatin 80mg/tab ½ tab OD PO
Frontal and maxillary sinuses are clear on qHs
transillumination and are non-tender to 4. Ranitidine 150mg/tab 1 tab BID PO
palpation and percussion  Provide photocopy of labs
 Clinic follow up on Friday 2-17-12 please
MOUTH AND PHARYNX: call clinical 1 day before
24
have a clear division. Their toilet is flush type
and in an open drainage. Electricity is supplied
by VECO. Their water is supplied by VECO for
cleaning purposes. Mineral water in a
dispenser is used for drinking. Their garbage is
collected twice a week. Transportation is
easily accessible. The distance of there house
from the main road, grocery, health center,
Barangay Hall and fire station is 50 meters;
drug store is 100 meters and hospital and
church is about 150 meters away. Crowding
index is 4:7. His PRN medications are stored in
a canister inside his closet. Cleaning supplies
are found inside the comfort room. There is
peace and order in the area and patient claims
that he doesn’t have any problem dealing
with his neighbors with the verbalization of
“Sukad-sukad, wala ramay gubot sa amo, di
man pud na sila mag shinagitay. Mag-away
away pero di gyud ingon ana ka grabe nga
mabalda na gyud mi.”
2. Nutrition metabolic pattern
Patients weight before hospitalization is 54 kg
and currently he weighs 45 kg. His current
height is 5’4 with a BMI of 19.68. He feels
good about his weight. Patient said “Dali rman
ku mudaot day pero lisod kau ku manambok”.
He has a fair appetite.
Usual and 24 hour diet recall
24 hour Usual diet
recall
Breakfast 1 cup 1 glass
(7am) vegetable, coffee, 1 cup
1 cup rice rice and
and 1
glass milk
Upper and lower lips both dark pink, smooth,
and moist without lesions or swelling; Buccal
mucosa pinkish, smooth and moist without
lesions; stenson’s duct visible without redness or
swelling or pain.
Tongue is moist, pinkish, and at midline without
lesions, nodules, or fasciculations; papillae
present on dorsal surface; ventral surface
smooth and shiny pink with small visible veins
present
No unusual or foul odor noted; uvula pinkish,
moist, hangs freely in midline without redness or
exudate; tonsils 1+, pink, symmetric, without
exudates, swelling, or lesions; gag reflex intact, ,
tooth decay noted on left upper molar.
NECK:
Symmetric, supple, with head centered; thyroid
gland move upward as client swallows; full,
smooth, controlled ROM; trachea at midline;
lymph nodes are nonpalpable.
CHEST AND LUNGS:
Refractions and bulges not noted; respiration is
relaxed, regular, effortless, and quiet without the
use of accessory muscles; no tenderness, pain, or
unusual sensations reported; crepitus not noted;
fremitus symmetric; audible secretions were
heard upon auscultation on both upper lung
fields of the lungs
HEART AND PERIPHERAL VASCULATURE:
Heaves not noted; apical impulse at fifth
intercostals space, midclavicular line; no thrills or
unusual pulsations noted; S1 distinct, heard best
at apex, S2 sound distinct , PR= 72bpm, heard
25
 Lunch(12noon) 1 cup 2 cups rice, best at aortic and pulmonic area; extra heart
vegetable, 2 slices pork sounds and murmurs not noted; bruits not
1 cup rice and noted. Arms and legs bilaterally symmetric; no
and 1 edema noted.
glass milk Both upper and lower extremity exhibited a
capillary refill time of 2 seconds.
Dinner(6pm) 1 cup 1 cup rice, Allen test right and left ulnar and radial arteries
vegetable, humba and patent, pinkish color returns to palms within 3
1 cup rice 2 glasses seconds; varicosities not noted.
and 1 water
glass milk ABDOMEN:
Snacks(3pm) biscuit 1 cup rice, 1 Gravid abdomen; striae noted on hypogastric
and milk glass energy region; umbilicus at midline, recessed, without
drink(cobra), bulging; soft gurgle sounds heard at abdomen at
1 piece the rate of 18 clicks per minute.
chicken
BACK AND EXTREMITIES:
Posture and gait not assessed because client was
Patient works as a consultant. He doesn't
confined in bed.
exercise. He dont have any food preferences
Full range of motion for right shoulders, arms,
and dislikes. When the patient is in stress he
elbows, wrist, hands and fingers; full range of
responds to it by eating a lot with the
motion for right hips, ankles, and feet; crepitus
verbalization of " Kung ma stress ku day kay
not noted; bony deformities not noted. His both
mukaon jud ku bahala nalang". They are 6 in
Left upper and lower extremities can’t move
the house and his wife is the one who shops
voluntarily.
there food. Their helper will be the one to
cook and prepare the food for them. Patient
Muscle strength:
said that the income is adequate for the
Right upper extremity: 5/5
needs of his family by stating " Sakto rman
Left upper extremity: 2/5
amu income day, makakaon rami ug sakto".
Right lower extremity: 5/5
When asked, patient was able to enumerate
Left lower extremity: 3/5
the three basic food groups Go, Grow and
Glow and was also able to give examples
Scales for grading muscle strength:
under each food group. He said that foods rich
5 – Active motion against resistance
in carbohydrates include rice and bread and
4 – Active motion against some resistance
foods with low nutritional value includes junk
3 – Active motion against gravity
foods.
2 – Passive ROM
1 – Slight flicker of contraction
3. Elimination Pattern
0 – No muscular contraction 26
 APPENDIX A

GENOGRAM

Legend:

Female Deceased

Male

Patient

CANCER

APPENDIX B
27
 DRUG STUDY

Citicholine IVTT q6H
CLASSIFICATION: anti-bacterial
ACTION: Citicholine activates the biosynthesis of structural phospholipids in the neuronal
membrane, increases cerebral metabolism and increases the level of various
neurotransmitters, including acetylcholine and dopamine. Citicholine has shown
neuroprotective effects
:Inhibits bacterial DNA gyrase thus preventing replication in susceptible bacteria
INDICATION: Cerebrovascular Disease
ACTION: inhibits HMG CoA reductase, the enzyme that catalyses the first step in the
cholesterol Synthesis pathway, resulting in a decrease in serum cholesterol, serum LDLs and
increase in serum HDLs; increases hepatic LDL recapture sites; enhances reuptake and
catabolism of LDL; lowers triglyceride levels
INDICATION: adjunct to diet as treatment of elevated total cholesterol serum, serum
triglycerides and LDL cholesterol
CONTRAINDICATION:
hypersensitivity to atorvastatin, Fungal by products, hepatic disease, pregnancy, lactation;
Used cautiously with impaired endocrine function, history of liver disease, alcoholism

CONTRAINDICATION: hypersensitivity to the drug ADVERSE EFFECTS:

Hypertonia of the parasympathetic nervous system Headache, asthenia, flatulence, abdominal pain, cramps, constipation, nausea, dyspepsia,
Use cautiously for pregnancy and lactation, renal and hepatic damage heartburn, liver failure, sinusitis, pharyngitis, arthralgia, myalgia

ADVERSE EFFECTS: Fleeting and discrete hypotension effect, increased parasympathetic NURSING CONSIDERATIONS:
affects, low blood pressure, itching, swelling in face or hands, chest tightness, rash, diarrhea, Assess for allergy to atorvastatin, fungal byproducts; active
nausea, vomiting, anorexia hepatic disease; acute serious illness;
Administer drug without regard to food
NURSING CONSIDERATIONS: Assess for hypersensitivity to penicillins, cephalosporins Monitor serum cholesterol and LDL
Take Citicholine as prescribed Give medication at bedtime for highest cholesterol synthesis
Monitor neurologic status
Note for sign of slurring of speech Senokot forte 2 tabs OD qHS
Provide safety measures CLASSIFICATION: laxative
Monitor for adverse effects ACTION: Senokot preparations contain glycosides which, upon ingestion, exert no
Store medication away from heat and direct sunlight action in the stomach or small intestine. In the colon, enzymatic action converts the
inactive glycosides into active aglycones which act specifically in the large bowel
Atorvastatin 80 mg/tab 1 tab OD qHS through the auerbach’s plexus to stimulate peristalsis.

CLASSIFICATION: antihyperlipidemia INDICATION: constipation

HMG CoA reductase inhibitor
CONTRAINDICATION:

28
Hypersensitivity to senokot, do not use when abdominal pain, nausea, vomiting, or other Assess for epigastric or abdominal pain
symptoms of appendicitis are present, acute abdominal disease, intestinal haemorrhage, or -CNS precautions
obstruction , or persistent diarrhea -Instruct patient to avoid alcohol, products containing aspirin 
ADVERSE EFFECTS: diarrhea, nausea, vomiting, rectal irritation, stomach cramps or bloating, and NSAIDs and foods that may cause an increase in GI irritation
rapid heart rate, rectal bleeding, weakness, dizziness, fainting, sweating, skin rash, -Encourage oral fluids and fiber intake, it may minimize 
unrelieved constipation Constipation
-take full course
NURSING CONSIDERATIONS: - Advise not to smoke because it interferes with action of medication
Assess hypersensitivity to the drug -Instruct patient proper use of OTC medication
Assess for abdominal pain, nausea, vomiting, symptoms of appendicitis, intestinal
hemmorhage, persistent diarrhea
Inform client that urine may turn to pink which is normal Allopurinol 300mg/tab 1 tab OD PO PC
Store medication away from heat Classification: Xanthine oxidase inhibitor, anti-gout
Monitor stool output
Provide safety measures such as siderails, pillows, adequate lighting Action: inhibits the enzyme xanthine oxidase, thus interfering the oxidation of purines.
Normally, all the purines are converted into hypoxanthine then to uric acid. There is reduced
Ranitidine 110mg 1 tab BID PO oxidation of hypoxanthine to xanthine and xanthine to uric acid thus there is reduction of
uric acid levels
Classification: histamine h2 antagonists
Indication: treatment of hyperuricemia
Action: inhibits the action of histamine at the H2 receptor site located primarily in gastric
parietal cells resulting in inhibition of gastric acid secretion Contraindications: Hypersensitivity

Indication: active duodenal and gastric ulcer Adverse Effects: hypotension, dizziness, bradycardia, heart failure, rash, urticarial

Contraindication: Hypersensitivity, hepatic dysfunction Nursing Responsibilities:

-Assess uric levels
Adverse Effects: arrhythmias, constipation, diarrhea, confusion, hallucinations, dark stools, -Encourage oral fluids to promote flushing and to prevent stone formation
altered taste - Inform patient that drug may cause skin irritation
- Encourage patient to avoid purine-rich foods such as crabs, chicken, ham, organ meats,
Nursing Responsibilities: nuts, noodles, sardines and salmon

29
 APPENDIX C

DISCHARGE PLAN

Medications -Refer immediately if unusual signs are noted

- Advised to do hand washing as often as possible
-Stressed out the importance of compliance of take home medications
-Instructed to take the right drug at the right time, dose, frequency, route - Stressed importance of adhering to prescribed diet
-Discuss with the client about the contraindications and the effects of the drugs being given
-Have client report if any adverse effects occur
OBSERVABLE SIGNS AND SYMPTOMS
-Advise patient not to discontinue any medications without consulting the physician
-Instructed client to report to the doctor when signs and symptoms of hypertension occur.
-Instruct the client to report if blood pressure is high (systole is > 140 and diastole is >90)
ENVIRONMENT -Instructed to report for recurrence of symptoms
-Keep surroundings clean and hazard free
-Instruct client to maintain a conducive environment for rest and sleep DIET
-Avoid stressful environments like places with noise or crowding -Taught client to reduce intake of food rich in saturated fats
-Provided a comfortable environmental temperature -Instructed client to reduce diet rich in cholesterol
-Encouraged client to stay in a well-ventilated room for fresh air -Instructed client to eat a healthy diet that is rich in vegetables and fruits. Avoid saturated
-Instructed to stay away from hazardous places that could lead to injury
and trans fats. 
-Dietary protein should come primarily from fish and plant sources (soy, beans, legumes).
TREATMENT
-Stressed out to eat at the right time with the right amount
-Instructed client to have follow up check up with physician on scheduled date
-Drink enough water daily (at least 8-10 glasses a day)
-Instructed to take full course of the medication regimen as prescribed
-Stressed the importance of the compliance of treatment
SPRITUALITY
-Continue to attend Mass every Sunday for reflection
HEALTH TEACHINGS
-Continue reading the bible for guidance and enlightenment
-Instructed client to maintain ideal weight
-Continue to build up hope and faith in the plan or will of God
-Instruct client to have regular blood pressure checked to see progress
-Count your blessings everyday
-Instructed to avoid stress as much as possible in order to prevent further complication
-Pray as a family as much as possible
-Instructed to balance activities with rest and scheduling activities to promote sleep 

30
31