I.

INTRODUCTION Hypertension is a persistent or intermittent elevation of systolic arterial blood pressure above 140 mmHg or diastolic pressure above 90 mmHg. It is classified by three types. Primary (essential) accounts for over 90% cases and is after referred to as idiopathic, since the underlying cause is not known. This type as an insidious onset with few, if any, symptoms so it is often not recognized until complications have occurred. Secondary hypertension results from a number of conditions that impair blood pressure regulation. A severe or accelerating form of hypertension, malignant hypertension, results from either type and can cause blood pressure as high as 240/140 mmHg possibly leading to coma and death. It is estimated that about 25% of all people older than age 18 years have hypertension. It remains to be the number one risk factor for cardiovascular disease. It is also one of the top causes for death, according to a 2005 report of the WHO (World Health Organization). Data gathered from the Philippine Heart Association states 17-22% incidence of hypertension among Filipinos. Only 14% of the Filipinos who do have hypertension recognize that they do carry the condition; 86% still enjoy sedentary lifestyle, unaware of its ill effects on health. On the other hand, about 60 million American have hypertension and approximately 22 million of them do not know they have it. Approximately two-thirds of Americans over the age of 65 have systolic hypertension, usually related to underlying atherosclerosis and stress. Younger individuals may also be affected, depending on the number of risk factors present. Malignant hypertension affects men more often that women, with the average age at diagnosis being 40 years of age. Risk factors of hypertension include age, sex (male: 45 and above, female: 55 and above), obesity, food intake (hi fat, hi calorie, and hi sodium diet), sedentary lifestyle, smoking and alcohol, emotional status (stress, fear, anxiety, etc), race (more prevalent and sever in African Americans), drugs/medications, and family history of hypertension. The group has chosen this case because apart from hypertension, the client likewise suffered from intracerebral hematoma and had undergone craniotomy which makes it quite a rare case. Moreover, the patient has paralysis on his right extremities which may be either due to neurological deficit or cerebrovacular accident prior to admission. The client also consumes alcohol regularly which aggravated his condition.

OBJECTIVES To be able to learn more about hypertension and its underlying causes and risk factors To be able to learn the disease process and appropriate medical treatment To be able to improve the state of the client and his environment which are predictors of health outcome in all situations To identify health patterns of the client receiving care To help improve clients ways in coping with condition and stress which are interwoven in his

II. ASSESSMENT PERSONAL DATA Reynaldo Peaflor was born on April 18, 1955 and is presently 55 years old. He resides at the LMB compound, Alabang, Muntinlupa City. He sells fish in the market for a living. He is a Roman Catholic who is a devotee of the Nazarene in Quiapo, where he goes about one to two times every month. His wife already passed away and now left with his six children, in which only two are females and the others are males. He lives alone in his home although 4 of his children live in the same compound. CHIEF COMPLAINT/S He was found unconsciously lying in his bathroom floor. His family suspected it as an effect of hypertension. HISTORY OF PRESENT ILLNESS According to the patients son, Raymond, his father has been experiencing occasional blurred vision for about a month prior to his admission in the hospital. He did not seek any consultation for this matter. He took maintenance drugs for hypertension but his sin failed to remember the names. In the early morning of May 30, 2010, his nephew found him unconsciously lying in his bathroom. From there, Reynaldo was rushed to the hospital. His family alleged that it was because of his high blood pressure since they knew that Reynaldo was suffering from the said condition. PAST MEDICAL HISTORY Mr. Peaflor had no major childhood illnesses except for common cough and colds. He has no allergies in food, thus he eats whatever he wants, and the same applies for drugs too. He completed all immunizations when he was a child. This was the first time he got confined in his entire life. FAMILY HEALTH HISTORY Another son of Reynaldo, Rommel, states that the only family disease that he knows of which their family has is hypertension. Reynaldos wife and father both suffered from hypertension and passed away due to Cerebro Vascular Accidents. None of his six offsprings are hypertensive though.

FUNCTIONAL HEALTH PATTERNS (MARJORIE GORDONS) PATTERNS OF PRIOR TO DURING HEALTH HOSPITALIZATION HOSPITALIZATION Health Perception He is healthy Weak and unable and Health He does not use to move right Management Pattern extremities tobacco in the present nor the On complete bed past rest with no bathroom He drinks alcohol privileges (Around 500ml gin, and 1000ml Feels dependent beer per day) 5-7 on the health care times a week team He does not He expects that he engage in regular would be cured check-ups while in the hospital He thinks his illness is due to Expects the family history medical staff to assist and help Does not believe him in every way in albularyos Takes OTC drugs in case of illness Nutritional and No problem with Osteorized Metabolic Pattern his appetite feeding only (240ml every 4 Eats 3 rice meals hours) per day and sometimes snacks He lost weight Drinks 1-1.5 liters of water everyday No food or eating discomforts No significant dental problem ANALYSIS AND INTERPRETATION Multiple studies have demonstrated bet. consumption of more than 1-2 ounces of alcohol per day and the development of HPN (Medical-Surgical Nursing: Total Patient Care Harkness; Dincher)

Elimination Pattern

Defecates once a day of normal, formed stool

Dietary management for HPN can be accomplished through moderation of dietary sodium; adequate intake of K, Ca, and Mg; reduction of dietary saturated fats and cholesterol, and reduction in caloric intake for those who are overweight (Medical-Surgical Nursing: Total Patient Care Harkness; Dincher) Has not defecated Increased excretion yet since his of urine results a reduction in plasma operation

without any discomfort Normal urinary elimination pattern

Activity Exercise Pattern

Being a fish vendor is a form of an ample amount of exercise everyday He can take full self care of himself Approximately does 7hrs of deep, continuous sleep

He is unable to do activities of daily living without any assistance Unable to do strenuous activities Has difficulty falling asleep Sleeps shallowly for approximately 5 hours but not continuous No troubles of hearing Unable to talk does not respond well except for facial grimace when in pain Feels sad because of hospitalization Wants to be cured as soon as possible for him to go back to his normal life outside the hospital

Sleep Rest Pattern

volume, cardiac output, and renal blood flow, thus lowering BP (Medical-Surgical Nursing: Total Patient Care Harkness; Dincher) A regular program of exercise yields a modest decrease in BP in patients with stage I and II HPN. (Medical-Surgical Nursing: Total Patient Care Harkness; Dincher) One of the universal self care requisites is maintaining balance between activity and rest to achieve wellbeing (Dorothea Orem: Self-Care Deficit Theory)

Cognitive Perceptual Pattern

No troubles of hearing Wears eyeglasses (250/250)

Self-perception and Self-control Pattern

Describes self as an ordinary fish vendor Experienced occasional blurring of vision

The counseling role of a nurse strengthens the nurse-patient relationship as the nurse becomes a listening friend, an understanding family member, and someone who gives sound and emphatic advises (Hildegard Peplau: Interpersonal Relations Theory)

Role Relationship Pattern

Lives alone; some children live in the same compound though Usually socializes with friends at work

His children take turns in taking care of him in the hospital

Establish rapport the nurse and the sick person are relating as human being to human being for the patient to feel that he is not all alone. He can have a friend inside the hospital (Humanto-Human Relationship Model: Joyce Travelbee)

Sexuality Reproductive Pattern

Coping Pattern

Stress

He has six children 4 males and 2 females Sexually inactive due deceased wife When in a lot of stress he sometimes prefers to drink to temporarily forget it Keeps problems to himself

Value Pattern

Belief

He goes to Quiapo once or twice a month He is a devotee of the Nazarene

Although relaxation techniques and biofeedback are not recommended for definitive treatment of HPN, some patients do find them beneficial (MedicalSurgical Nursing: Total Patient Care Harkness; Dincher) He is unable to go Rendering cultureto church since he specific care is an essential goal in is in the hospital nursing. It leads to a high credibility, conformability, and wealth of empirical data Madeleine Leininger (Theoretical Foundations of Nursing by Octaviano; Balita) Does not mind any other problem now but his illness

PHYSICAL ASSESSMENT Normal Findings Skin Uniform in color No Edema When pinched, skin springs back to normal state. Moist; smooth texture No abrasions or lesions Actual Findings Uniform in color (+) edema in lower extremities. Springs back to normal state. Moist; wrinkled texture (+) bruises

Head

Normocephalic shape Size proportion to body Smooth skull contour Absence of nodules, masses, or depressions Symmetric facial features and movements.

Normocephalic shape Size proportion to body (+) lesions on left front skull Facial features symmetric Non symmetric facial movements.

Hair

Evenly distributed Thick hair Silky and resilient No infection of infestation Color may vary

Not evenly distributed Thin hair Not silky but resilient No infection of infestation Gray in color

 Nails

Convex curvature Nail plate at about 160 Smooth texture Pink in color Capillary refill test (less than 4 seconds)

Convex curvature Nail plate at about 160 Smooth texture White in color (+) capillary refill test

Eyes

Eyebrows: hair evenly distributed; symmetrically aligned Eyelashes: equally distributed; curved slightly outward Lids close symmetrically Sclera appears white; no scars or pigmentation Conjunctiva: shiny, smooth and pink Pupils: black in color; equal size Both eyes move in unison Corneal reflex: smooth, transparent; blinks when touched Bean-shaped Color same as facial skin Symmetrical Auricle aligned with outer canthus of eye Pinna: mobile, firm, and not tender Normal voice tones audible Sounds heard on both ears

Eyebrows hair evenly distributed; symmetrically aligned Eyelashes: equally distributed; curved slightly outward Lids close symmetrically Sclera appears white; no scars or pigmentation Conjunctiva: shiny, smooth and pink Pupils: black in color and equal and size Both eyes move in unison Corneal reflex: smooth, transparent; blinks when touched Bean-shaped Color same as facial skin Symmetrical Auricle aligned with outer canthus of eye Pinna is mobile, firm, and not tender Normal voice tones audible Sounds heard on both ears

Ears

 Nose

Symmetric and straight No discharge or flaring Uniform in color Nasal septum intact and in midline

Symmetric and straight No discharge or flaring Uniform in color Nasal septum intact and in midline NGT in place

Mouth

Neck

Lips: pink color; soft moist, smooth texture; symmetrical Teeth: smooth, white, shiny tooth enamel Tongue on central position; pink and moist; slightly rough with whitish coating; moves freely Palates and uvula smooth and pink Uvula in midline of soft palate Muscles equal in size; head centered No discomfort in moving No vein engorgement No visible pulsation No masses or tenderness

Lips: pale pink in color, choppy, symmetrical Teeth: smooth, slightly yellowish Tongue on central position; pink and moist; slightly rough with whitish coating; moves freely Palates and uvula smooth and pink Uvula in midline of soft palate Muscles equal in size; head centered No discomfort in moving No vein engorgement No visible pulsation No masses or tenderness

 Thorax and Lungs

Spine vertically aligned Percussion notes resonance Quiet, rhythmic, and effortless respirations Costal angle less than 90

Spine vertically aligned Percussion notes resonance Quiet, rhythmic, and effortless respirations Costal angle less than 90

Abdomen

Uniform in color Flat or rounded (convex) No evidence of enlargement of liver and spleen Symmetrical movements caused by respiration With consistent tension; no tenderness

Uniform in color Flat or rounded (convex) No evidence of enlargement of liver and spleen Symmetrical movements caused by respiration With consistent tension; no tenderness

Musculo - Skeletal

Muscles: equal sizes on both side of body Coordinated movements No deformities No tenderness or swelling on bones and joints Joints move smoothly

Muscles are equal on both sides of the body Uncoordinated body movements No deformities Tenderness noted on R elbow and knee. Joints on left side of the body moves smoothly; difficulty in moving joints on right side of the body

III. ANATOMY AND PHYSIOLOGY

IV. PATHOPHYSIOLOGY

Precipitating Factors: Hypertension Hyperlipidemia Diabetes Mellitus Heart Diseases Atherosclerosis Arteriosclerosis Thrombosis Severe dehydration

VASOCONSTRICTION

Blockage of the blood vessel Embolism Lack of oxygen & nutrients supply

Predisposing Factors: Life style (sedentary) Vices(Alcohol, smoke) Age Diet Sex Heredity Self-medication

Ischemic Stroke

High blood pressure, smoking, heart diseases, diabetes, narrowing of arteries supplying the brain, unhealthy lifestyle

Cerebral Ischemia

Hypoxia Subarachnoid Hemorrhage

High blood pressure, smoking, and a family history of burst aneurysms.

- Cell death - Decreased Oxygen level Intracerebral hemorrhage

Altered cerebral metabolism Venous Stroke

Decreased cerebral perfusion

Severe dehydration, severe infection in the sinuses of the head and medical or genetic conditions that increase a persons tendency to form blood clots

Large Artery Strokes Local Acidosis Lost or abnormal sensation and paralysis on one side of the body affected by Transient Ischemic Attack

Hypertension, diabetes, smoking and high cholesterol levels

Same with Ischemic stroke

Cytotoxic Edema

Aneurysm Rupture

Small Artery Stroke

Hypertension, diabetes and smoking

Embolic strokes

Irregular heart beat (atrial fibrillation), a heart attack (myocardial infarction), heart failure or a small hole in the heart called a PFO (Patent Foramen Ovale).

Brain tissue Necrosis V. MEDICAL SURGUCAL MANAGEMENT Death

Severe Cases

SURGICAL MANAGEMENT Patient was brought to operating room with operative diagnosis of cerebrovascular disease bleed and hypertension under surgeons Dr. Hufana and Dr. Jumao. Time operation started in OR was 9:49PM and operation ended at 11:00PM. Anesthesiologist is Dr. Ascalon. Agent used was Sevorane. Duration of anesthesia was from 9:20PM to 11:00PM. Operation performed was left frontal craniotomy and evacuation of intracranial hematoma. Procedure was done to remove blood clot on the left frontal hemisphere of the brain Procedure was guided by CT scan imaging results Incision was done at the left frontal hemisphere, right above the forehead Intracranial hematoma was removed Incision is secured with a soft wire Incision is secured with staple wires as sutures Sterile gauze applied at the site of incision and regularly changed Right after surgery, patient is tested with Glasgow Coma Scale Special leg stockings are used to prevent blood clot formation Staple wires closing the scalp were removed by the surgeon on June 26, 2010, at around 7AM by Dr. Hufana

PHARMACOLOGICAL MANAGEMENT Date ordered: June 15, 2010 Name of drug Classification Indication Dosage and route Side effects/ adverse effect Nursing consideration

Generic Name: Ketorolac Tromethamine Brand Name: Toradol,

Central nervous system agent, Non-steroidal inflammatory drugs, analgesic; antipyretic

Short term (< 5 days) of moderate to severe, acute pain as continuation therapy from IV/IM.

30 mg IM/IV q6h.

Side Effects: Headache, drowsiness, dizziness Adverse effect: Nausea, dyspepsia, GI pain, diarrhea, edema

Assess LFTs, renal function, and coagulation profile Assess for history of CABG surgery, asthma and allergic reaction to aspirin or other NSAIDs. Monitor for hypersensitivity reactions.

Date ordered: June 16, 2010 Name of drug Classification Indication Dosage and route Side effects/ adverse effect Nursing consideration

Generic Name: Amlodipine besylate Brand Name: Norvasc

Cardiovascular agent, calcium channel blocker; antihypertensive agent.

To control hypertension

5 mg/day to 10 mg/ day PRN PO.

Side effect: Dizziness, fatigue, headache Adverse effect: Anxiety, lethargy, tremor, arrhythmias, hot flashes, palpitation, pharyngitis, weight loss

Use amlodipine cautiously in patient with heart block, heart failure, impaired renal function, hepatic disorder, or severe aortic stenosis. Monitor blood pressure while adjusting dosage, especially in patient with heart failure.

Date Ordered: June 16, 2010 Name of drug Classification Indication Dosage and route Side effects/ adverse effect Side effect: Gastrointestinal disorders, Itching or hives, swelling in your face or hands, swelling or tingling in your mouth or throat, chest tightness, trouble breathing, or rash, Low blood pressure (faintness, dizziness), Slow or fast heartbeat, Headache, Nausea, vomiting, or diarrhea (loose BMs) Adverse effect: citicoline may exert a stimulating action of the parasympathetic, as well as a fleeting and discrete hypotensor effect Nursing consideration

Generic Name: Citicoline Brand Name:

Neuroprotective, CNS Drugs & Agents for ADHD

Cerebrovascular Diseases, accelerates the recovery of consciousness and overcoming motor deficit

Oral drops 1ml

Zynapse

Verify the doctors order. Assess allergy to warfarin. Do not use rug if the patient is pregnant (use contraceptives). Monitor closely PT ratio and INR. Administer the drug in IV form if the client cannot take it orally. Document the procedure. Zynapse must not be administered in conjunction with medication containing meclofenoxate (also known as clophenoxate).

Date ordered: June 15, 2010 Name of drug Classification Indication Dosage and route Side effects/ adverse effect Nursing consideration Assess pt. for fever and pain Assess allergic reaction and hepatotoxicity Monitor liver and renal failure Tell the patient to notify prescriber for pain or fever lasting for more than 3 days.

Generic Name: Paracetamol Brand name: Biogesic

Analgesic/ antipyretic

Relief of mild to moderate pain; treatment for fever

500mg/1tab for T>37.8C Q4 PRN

Side Effects: Stimulation, drowsiness, nausea and vomiting Adverse Effects: Hepatotoxicity, renal failure

Date Ordered: June 16, 2010 Name of drug Classification Indication Dosage and route Side effects/ adverse effect Nursing consideration

Generic Name: Amikacin Sulfate Brand Name: Amikin

A broad-spectrum antibiotic derived from kanamycin. It is reno- and oto-toxic like the other aminoglycoside antibiotics.

Short-term 5mg/ml IM treatment of serious susceptible infections, including septicemia, respiratory tract, bones and joints, CNS (e.g., meningitis), skin and skin structure, intra-abdominal (e.g., peritonitis), burns and postoperative infections, complicated and recurrent UTIs or uncomplicated UTIs not susceptible to other antibiotics.

Side effects: Hypersensitivity to drugs, nausea, vomiting or weakness as your body adjusts to the medication Adverse Effects: Neuromuscular blockade, renal toxicity, vestibular and auditory toxocity

Weigh patient and review renal function of the patient before therapy begins. Assess the patient if he has hearing problem, allergy to drug and muscle disorder Assess the patient if pregnant Notify the doctor if the patient hear and feel ringing in your ears, hearing loss, unusual change in amount of urine, dizziness,

numbness, skin tingling, muscle twitching or seizures. Do not use this medication with other drugs that can cause nerve, kidney or hearing problems.

VI. COURSE IN THE WARD June 15, 2010 S/0 > (E4 V1 M5) disoriented + Facial grimace N pupil reactive 0xygen SNT: 98% HR: 70s-80s CBS- no refs. A > CVA bleed V/S monitoring P > Continued meds facilitate trasn-out June 17, 2010 Admitted as a case of CVA bleed started on Mannitol, Niardipnump and Citicholine, admitted in the ICU in day 3, Patient underwent craniotomy with evaluation of hematoma under GH in the ICU, patients BP persistently evaluated, Nicardippo dip wound, Amikacin, Ceftazidine also started, Patients then ordered MGH on day 14. LABORATORY HEMATOLOGY Examination Hemoglobin Hematocrit WBC count *Stab
*Neutrophile *Eosinophile *Basophile *Lymphocyte *Monocyte

May 30, 2010 Result 120 0.38 11.71

N/A 0.87 0 0 0.08 0.05

Reference 125-160 0.38-.50 5-10

0.00-0.01 0.40-0.60 0.01-0.06 0.00-0.01 0.20-0.40 0.02-0.08

Values g/L % 109/L

% % % % % %

Reticulocyte RBC Platelet Count Blood Typing Bleeding Time

0 4.78 299 N/A N/A

5-15 4.5-5.5 150-350

104/L 1012/L 109/L

2-4

Mins.

Clotting Time *MCV

*MCH *MCHC *MPV *ESR

N/A
79 25.1 319 9.10 N/A

7-15
86-100 26-31 310-370 9-13

Mins.
fL pg g/L fL

ROENTGENOLOGICAL REPORT X-RAY: (Chest AP) Findings: Both Lungs are clear Heart is magnified Rests of the visualized chest structures are remarkable Remarks: Cardiomegaly not ruled out is this AP study HEMATOLOGY Result Bleeding Tim Clotting Time Prothrombin Time:
*Patient *Control *% Activity *INR *APTT PT. *Control 12.6 13.5 107.14 0.93 27.4 32.8 10-14 secs. 11.4-15.8 secs. 70-100% 24.8-34.4 secs. 24.5-36.5 secs.

May 30, 2010

May 30, 2010 Reference 4.5-5.5 x 10/L 7-15 mins.

4 mins. 6 mins.

URINALYSIS Color: Light Yellow Appearance: Hazy Ph: 6.0 Specific Gravity: 1.030 Protein: Negative Sugar: Negative

June 02, 2010

Pus Cells: 2.3/HPF RBC: 10-12/HPF Bacteria: Few Mucus Thread: Few June 4, 2010 PROCEDURE CK-MB Specimen Received: Serum CLINICAL CHEM. 1 Examinations BUN Creatinine Troponin 1 Sodium Result 6.58
(May 30,2010)

Result 22.00

Reference 0.24 U/L

Reference Value 4.2 6.4 mmol/L M: 53-97 umol/L F: 142-339 umol/L

115.37
(May 30, 2010)

Negative
(June 04, 2010)

140.6
(May 30, 2010)

143.2
(June 08, 2010)

135 153 mmol/L

Potassium

3,54
(May 30, 2010)

2.61
(June 08, 2010)

3.5-5.3 mmol/L

4.61
(June 09, 2010)

OR RECORD: Patient: Mr. XY Operative Diagnosis: CUD Bleed, HPN Surgeon: Dr. Hufana, Dr. Jumao (Assistant) Time: 9:49pm to 11pm Anesthesiologist: Dr. Ascalon Agents used: Sevorant Anesthesia: 9:20pm 11pm Operation Performed: Left Frontal Craniotomy and evacuation of ICH CT SCAN Result:

June 5, 2010

May 30, 2010

Multi Axial tomograpic secretions of the head which contrast medium were obtained. The CT images reveal a hyper dense lesion with minimal surrounding edema in the left fronto-parietal lobe and lenticulocapsular area. It measures about 6.40 x 3.25 x 3.50 cm and has an estimated volume of 37.86ml The overlying cortical sulci, lateral fissures and cistems are effaced. The left lateral ventricle is compressed The right temporal horn is dilated Midline structures are displaced to the right No extra-axial collection noted The sella, pineal gland and posteria fossa structures including the brainstem and cerebellum are unremarkable The included portions of the orbits and paranasal sinuses are intact Both mastoids are sclerotic The bony calvarium is normal Impression: Acute parenchymal hemorrhage left frontal parietal lobe and lenticulo-cpasular area with subfalcine herniation Beginning non-communicating hydrocephalus

VII. NURSING CARE PLAN CUES NURSING DIAGNOSIS INFERENCE GOAL INTERVENTION RATIONALE EVALUATION

Subjective:

Objective: >inaccurate interpretation to stimuli >unable to speak dominant language V/S taken as follows: T: 37C PR: 81cpr RR: 21bpm BP: 120/80 mmHg

> Disturbed thought process related to physiological changes to be developed by head injury as evidenced by inaccurate interpretation of stimuli.

HEAD INJURY forces penetrates to the skull head trauma brain tissues & brain cells damaged DISORIENTATION

Long term: > After 2-3 days of nursing intervention patient would regain/maintain optimal level of mutation.

Independent >Provide quite/calm >Minimizes environment. environmental stimuli to reduce sensory overload. > Promote adequate rest. > Sleep deprivation may further impair cognitive abilities. > May aid in reducing confusion.

> Goal partially met. The patient regained minimal amount of optimal level of mutation.

Short term: > After 4-8 hours of nursing intervention would identify ways to compensate for memory deficits.

Collaborative > Communicate information in simple in simple short sentences

> Goal partially met. After 4-8 hours of nursing intervention, the patient showed some ways to compensate for memory deficit

CUES Subjective:

Objective: >disoriented >with right sided paralysis >demonstrates difficulty with mobility and activity.

NURSING DIAGNOSIS >Impaired physical mobility related to neuromuscular impairment to be developed by head injury as evidenced by right sided paralysis.

INFERENCE HEAD INJURY pressure damaged parts of the brain impaired cerebral circulation stroke neuromuscular impairment right sided paralysis PHYSICAL MOBILITY IMPAIRMENT

GOAL Long term: > After 2-3 days of nursing intervention patient will be able to maintain or increase strength and function of the affected body part.

INTERVENTIO N Independent > Keep side rails up and bed in low position. > Clean, dry, and moisturize skin as needed.

RATIONALE > This promotes a safe environment. > To maintain skin integrity.

EVALUATION > Goal met. The patient was able to maintain and increase strength and function of the affected body part.

V/S taken as follows: T: 37C PR: 81cpr RR: 21bpm BP: 120/80 mmHg

Collaborative > Monitor input Short term: and output record > After 4-8 hours and nutritional of nursing pattern. Assess intervention the nutritional needs patient will be as they relate to able to maintain immobility position of (possible function, free of hypocalcemia, complications of negative nitrogen immobility and balance). skin integrity as evidenced by intact skin.

> Pressure sores develop more quickly in patients with a nutritional deficit. Proper nutrition also provides needed energy for participating in an exercise or rehabilitative program.

> Goal met. The patient was able to maintain position of function, free of complications of immobility and skin integrity as evidenced by intact skin.

CUES Subjective:

NURSING DIAGNOSIS > Impaired verbal communication related to cerebral speech center injury as manifested by absence of ability to process information and system of symbols.

INFERENCE HEAD INJURY pressure damaged left hemisphere impaired cerebral circulation cerebral speech center impaired LOSS OF SPEECH

GOAL Long term: > After 2-3 days of nursing interventions patient will be able to establish methods of communication in which needs can be able to be expressed.

INTERVENTIO N Independent > Encourage patients attempt to communicate > Keep distractions like gadgets and radio

RATIONALE > To lessen patients sense of isolation and promotion of helplessness. > This will keep patient focused, decrease stimuli going to the brain for interpretation > Patients may have defect in

EVALUATION > Goal partially met. The patient was able to establish some methods of communication in which needs can be expressed.

Objective: >disoriented >unable to speak dominant language.

>Maintain eye contact with

V/S taken as follows: T: 37C PR: 81cpr RR: 21bpm BP: 120/80 mmHg

Short term: > After 4-8 hours of nursing intervention the patient will be able to demonstrate congruent verbal and non verbal communication.

patient when speaking. Stand close, within patients line of vision (generally midline).

field of vision or may need to see the nurses face or lips to enhance understanding of what is being communicated. >Fatigue may have an adverse effect on learning ability.

Collaborative > Consult a speech therapist for additional help. See that patient is wellrested before each session with the speech therapist.

> Goal partially met. The patient demonstrated some congruent non verbal kind of communication.

VIII. HEALTH TEACHING MEDICATIONS Before the patient leaves the hospital, tell about what the medications are for. Instruct patients companion to follow medications that are ordered by the doctor for the patient. EXERCISE Teach patients companion to perform ROM exercises to the patient promote good blood circulation especially on the part that is most affected. Since the patient cant move, teach family member and let her assist the patient. TREATMENT Advise patients companion to bring patient to attend a physical therapy session to improve his movements. Cheap physical therapy sessions are offered in barangay health centers. HYGEINE To promote full recovery, advise patients family member to monitor hygiene, it is to prevent infections or other related complications such as skin diseases and body odor. OUT-PATIENT Advise patients companion to accompany patient to attend all follow up check up for his monitoring. DIET Teach patients companion how to make osteorized feedings for the patient, with every essential nutrient part of the feedings Teach patients companion how to feed patient using a nasogastric tube, assessing the placement of tube in the stomach of the patient Advice patients companion to keep the nasogastric tube intact SPIRITUAL To obtain optimum health, spiritual status should always be considered. Advise patient and family members to get closer to God and always give thanks for another life.

IX. APPENDICES VITAL SIGNS June 03, 2010 @ 2:30am (first day) BP: 170/100 PR: 80 RR: 26 T: 36.4 June 05, 2010 @ 8:00 pm (day of operation) BP: 160/803 PR: 67 RR: 21 T: 37.3 June 06, 2010 @ 12:00 am (after operation) BP: 110/60 PR: 87 RR: 16 T: 37.1 June 17, 2010 @ 12:00 am (last day ICU) BP: 150/100 PR: 73 RR: 23 T: 37.1 June 21, 2010 @ 12:00 am (ward rm. 310A) BP: 130/80 PR: 78 RR: 20 T: 36 June 22, 2010 @ 4:00 am BP: 120/80 PR: 83 RR: 22 T: 37

June 27, 2010 @ 4:00 am BP: 110/70 PR: 93 RR: 18 T: 36.3

INTAKE and OUTPUT June 03, 2010 @ 10-2am (1st day) Intake Output Oral Parenteral Total Urine Drainage 500 470 970 900 June 05, 2010 @ 10-2am (day of operation) Intake Output Oral Parenteral Total Urine Drainage NPO 820 820 1570 June 06, 2010 @ 10-2am (after operation) Intake Output Oral Parenteral Total Urine Drainage 320 650 1170 1500 June 19, 2010 @ 10-2am Intake Output Oral Parenteral Total Urine Drainage 600 600 600 June 21, 2010 @ 10-2am (ward rm. 310A) Intake Output Oral Parenteral Total Urine Drainage 230 230 1200 June 22, 2010 @ 10-2am Intake Output Oral Parenteral Total Urine Drainage 230 230 480 -

BM 1x

Total 900

BM -

Total 1570

BM 2x

Total 1500

BM -

Total 600

BM 1x

Total 1200

BM 1x

Total 480

CBG Normal: 70-110 mg/dL June 03, 2010 (1st day) Time Result 11am 106 7am 102 3pm 93 June 04, 2010 Time Result 3pm 136 11am 147 7pm 99

Room ICU ICU ICU

Room ICU rm. 310A rm. 310A

June 05, 2010 (day of operation) Time Result Room 9:30am 109 OR 7pm 109 ICU June 06, 2010 (after operation) Time Result Room 9:30am 205 ICU 3:30pm 74 ICU 3:30am 91 ICU June 07, 2010 Time Result Room 9:30pm 133 ICU 3:30am 102 ICU June 09, 2010 Time Result 7:30am 77 3:30pm 79 7:30pm 93

Room ICU ICU ICU

June `10, 2010 Time Result 7:30pm 97 3:30pm 84 7:30am 91 3:30am 86 June 12, 2010 Time Result 3:30pm 97 7:30am 91

Room ICU ICU ICU ICU

Room ICU ICU

June 13, 2010 Time Result Room 7:30am 100 ICU 3:30am 95 ICU June 14, 2010 Time Result 7:30pm 95

Room ICU

June 15, 2010 (1st day) Time Result Room 1:30pm 172 ICU 7:30am 99 ICU 1:30am 102 ICU

Time

Eyes open 3 3 3 2 2 4 4 3 2 3 2 1 2 1 1 2

GLASGOW COMA SCALE

Verbal response 2 1 1 1 1 2 2 2 1 1 1 1 1 1 1 1

Motor response 5 6 6 6 5 5 5 5 6 6 5 5 5 5 5 5

Total

R arm L arm

R leg L leg
0-1/12

R pupil L pupil

Reaction

5/30 12pm10pm

10 10 10 9 8 11 11 10 9 10 8 7 8 7 7 8

0-1/1-2 1/3-4 1/3-4 1/3 1/2-3 1/3 1/3 1/3 1/3 1/3 1/3 1/3 1/3

1/1 2/2 2/2 2/2 2/2 2/2 2/2 2/2 2/2 2/2 2/2 2/2 3/3 3/3 2/2 3/3

+/+ +/+ +/+ +/+ +/+ +/+ +/+ +/+ +/+ +/+ +/+ +/+ +/+ +/+ +/+ +/+

5/31 11pm-6am 7am-10pm 11pm-6am 6/01 7-2 3-10 11-6 6/2 7am10pm 11-6am 6/3 7am6am 6/4 7am11pm 6/5 11pm6am 7am-2pm 3-10 6/6 11pm6am 7am-2pm

1/3-4 1/3-4 1/3 1/3 1/3 1/3 1/3 1/3 1/3 1/3 1/3 1/3 1/3 1/1

GLASGOW COMA SCALE

Time

Eyes open 4 4 4 4 4 4 4 4 4 4 4 4 3 3 3 2 3 3

Verbal response 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

Motor response 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5

Total

R arm L arm

R leg L leg 1/3 1/3 2/2 1/9 2/4 -3 1/3 2/3

R pupil L pupil

Reaction

3-10 11-6 6/7 7-2 3-10 11-6 7-2 6-10 3-10 11-6 6/9 7-2 3-10 11-6
6/10 7-2

10 10 10 10 10 10 10 10 10 10 10 10 9 9 9 8 9 9

1/3 1/3 2/2 1/9 1-2/4 1/3 1/3-4 2/4

3/3 3/3 3/3 3/3 3/3 3/3 3/3 3/3 3/3 3/3 3/3 3/3 3/3 3/3 3/3
2-3/2-3

+/+ +/+ +/+ +/+ +/+ +/+ +/+ +/+ +/+ +/+ +/+ +/+ +/+ +/+ +/+ +/+ +/+ +/+

3-10 11-6
6/11 7-2

3-10 11-6

3/3 3/3

Time

Eyes open

GLASGOW COMA SCALE

Verbal response

Total

R arm L arm

R leg L leg

R pupil L pupil

Reaction

Motor response
6/12 7-2

4 4 4 3 3 3 4 4 4 4 4 4 4 4 4 4 4 4

1 1 1 1 1 1 1 1 1 1 2 1 1 1 1 1 1 1

5 5 5 5 5 5 5 5 5 5 5 5 5 5 6 5 5 5

10 10 10 9 9 9 10 10 10 10 11 10 10 10 11 10 10 10

2/4 2/4 2/4 2/4 2/3 2/4 2/4 2/4 2/4 2/4 1 2/4 1-2/4 1-2/4 1-2/4 2/4 2/4 2/4 2/4

2/3 2/3 2/3 2/3 2/3 2/3 2/3 2/3 2/3 2/3
1-2/3-4

3/3 3/3 3/3 3/3 3/3 3/3 2/2 4/4 4/4 4/4 4/4 4/4 4/4 3/3 3/3
3/3

+/+ +/+ +/+ +/+ +/+ +/+ +/+ +/+ +/+ +/+ +/+ +/+ +/+ +/+ +/+ +/+ +/+ +/+

3-10 4-4
6/13 6-2

3-10 11-6
6/14 7-2

3-10 11-6
6/15 7-2

3-10

11-6
6/16 7-2

1-2/3-4

1-2/3 1-2/3 2/3 2/3 2/3 2/3

3-10 11-6
6/17 7-2

3-10
6/18 11pm6am

3/3 4/4

Time

Eyes open 4

GLASGOW COMA SCALE

Verbal response 1

Motor response 5

Total

R arm L arm

R leg L leg 2/3

R pupil L pupil

Reaction

7am-2pm

10

2/4

4/4

+/+

3-10
6/19 11-6 6/24

4 4 4

1 1 2

5 5 5

10 10 11

2/4 3/2 3/2

2/3 3/2 3/2

4/4 2-3/4 4/4

+/+ +/+ +/+