CASE PRESENTATION

OF
HEMORRHAGIC
STROKE

(Subarachnoid hemorrhage)
Presented By:

GROUP 3
Vernalin Terrado
Lerma Auman
Elenita Molina
Richelle Manlangit
Andres Jose
Bernard Bartolome
Marlen Tigno
Subarachnoid hemorrhage
 INTRODUCTION:

A Stroke, cerebrovascular Accident, or what is now being termed as

“brain attack” is a sudden loss of brain functions resulting from
disruption of blood supply to a part of the brain resulting from
pathologic blood vessels. It denotes an abnormality of the brain. Stroke
can be classified into ischemic and hemorrhagic strokes. Ischemic
stroke can be divided into thrombotic and embolic stroke. Thrombotic
stroke results from the narrowing or occlusion of blood vessels due to
fat deposits while embolic strokes result from the occlusion of a blood
vessel from a blood clot originating from the other parts of the body,
most commonly from the heart.
Hemorrhagic stroke is further classified into intracerebral
hemorrhage and subarachnoid hemorrhage. It results from the
rupture of blood vessels in the brain. Rupture of arterioles
result in bleeding into the parenchyma of the brain, while
rupture of larger arteries or its tributaries result in bleeding in
the subarachnoid space. Normal brain metabolism is impaired
by interruption of blood supply, compression and increased
ICP.

Usually due to rupture of intracranial aneurysm, AV

malformation, Subarachnoid hemorrhage.
Risk factors for hemorrhagic stroke includes age, gender, race,
hypertension, smoking and use of illicit drugs.

A stroke causes a wide variety of neurologic deficit, depending on

thelocation of the lesion,the size of the area of inadequate
perfusion and the amount of severity of blood flow. It may
include vomiting, headache, seizures, hemiplegia and loss of
consciousness. Pressure on the brain tissue from increase
intracranial pressure may cause coma and death.
General Objectives:

The primary concern of this study is to further

enhance the understanding of Cerebrovascular Accident
in congruence with the learned concepts of the Nursing
students.
Objectives of the Study:
This case presentation seeks to provide different
information about the disease to be presented about
the client being considered with the ff. specific
objectives:
1. Give a brief introduction about Cerebrovascular
Accident together with it clinical manifestations.

2. Present a theoretical framework for the study in

relation to a nursing approach applied to a patient
with hemorrhagic stroke.

3. Present the clients demographic and health history with

its Gordons eleven functional health pattern.
4. Present the abnormal results of the physical assessment and
compare it to the normal values or findings.

5. Present the different laboratory test and results done to the client
with its interpretation.

6. Discuss the normal Anatomy and Physiology of Circulatory and

Central Nervous System.

7. Explain the Pathophysiology of Hemorrhagic stroke

8. Identify Nursing Problems related to the situation and
case of the client

9. Discuss the drugs that has been used and prescribed to

the client by a drug analysis.

10. Present a Nursing Care Plan for the prioritized

problems of the client.

11. Show a Discharge Planning that the client may use

upon discharge to the hospital.
Theoretical Framework: Virginia Henderson
Difficulty of Impaired skin Urinary Loss of Poor
Breathing Integrity HPN dysfunction
Hyperthermia
consciousness
immobility Hygiene

Nursing intervention

Sleep and Keep

Move and
Eliminate Maintain rest and body
Sleep and maintain
Breath Eat and drink body wastes body temp Communicate clean
rest Desirable
Normally adequately with and well
postures
others groomed

Improved Health
 Comprehensive History:
Biographic History:
Name : D.A.C
City Address :Blk 14, lot 52 PVR-1, Norzagaray, Bulacan
Provincial Address :Romblon (Visayas)
Age : 53 years old
Gender : Male
Religious Affiliation : Roman Catholic
Marital Status : Married
Occupation : Unemployed (formerly a construction worker)
Source of Information : Daughter
Room & Bed No. : Male Ward Bed #9
Date of Birth : November 18, 1955
Diagnosis : Cerebrovascular Accident (subarachnoid
hemorrhagic)
Physician : Dr. Steve Conneroid
Chief complaint: : Loss of consciousness
Date of admission : January 05, 2009
Present Condition:

Two days prior to admission, the patient experienced high

blood pressure accompanied by low grade fever. At that
time, the client is having an argument with his daughter
that day before the time he was admitted which serves as
a triggering factor of his present illness. Upon admission
her daughter claim that her father experienced severe
headache followed by loss of consciousness. After series of
tests he was diagnosed to have experienced or suffered a
hemorrhagic stroke.
Past Medical History:

Three months prior to admission, the patient

Experienced intermittent flu and Arthritis in both knees.
While on this condition, the patient’s blood
pressure keeps elevating at a range of 150/90 mmHg
To 190/100 mmHg.
The patient also experienced a vehicular accident on
his bicycle two months ago, but no abnormal
manifestation has been observed aside from multiple
superficial wounds.
Family History:

The paternal side of the patient has a history of

pulmonary tuberculosis.

The maternal side of the patient has a history of

hypertension and heart disease.
Activities of daily living

A. Health perception and health management pattern

According to her, her father doesn’t go to the
doctor for consultation on his health status. He
seldom takes any medicine for his common
illnesses though he sometimes takes paracetamol to
relieve fever. She also states that her father is a
heavy alcohol drinker and cigarette smoker.the
patient self perception of health prior and upon
hospitalization is undermined because the patient
is in the state of coma.
B. Nutritional and Metabolic Pattern

Before the patient was hospitalized, he normally

eats fried chicken, especially the skin, chicharon and
processed meats such as tocino and longganisa. He
seldom eat vegetables and fruits. He prefers meat over
fish.
C. Elimination Pattern

Prior to admission the patient has a regular bowel

pattern but after he was hospitalized he was not able to
defecate for 3 days. He urinates 5 to 7 times a day with
a light yellow color before he is admitted, now he has
an indwelling urinary catheter draining dark yellow
urine.
D. Activity-Exercise Pattern

According to the patient’s daughter, her father

spends most of his time gambling or having a drinking
session with neighbors and friends. He doesn’t have a
job and he didn’t mind looking for one. He doesn’t help
in household chores instead he preferred spending his
time watching television.
E. Sleep – Rest Pattern

The patient has a habit of taking short nap in the

afternoon for 2 hours. In the evening he usually retires
at around 2:00am and usually sleeps for 3 hours. This
is primarily due to his fathers’ failing ability to
promote sleep.
F. Cognitive – Perceptual Pattern

The patient can read and write, he doesn’t have

hearing difficulty before he was hospitalized. He
doesn’t wear eyeglasses. His daughter said that her
father still possess a sharp memory and still recalls past
experiences with spontaneity. Her daughter also
reported that her father doesn’t have any speech
problem and has a normal sense of taste and smell
before he was hospitalized.
G. Self – perception and Self – Concept Pattern

According to the daughter her father verbalizes

that his contentment of a well balanced health
condition. Now his self- perception is undermined, since
the client is in the state of coma.
H. Role – Relationship Pattern

Significant people to the client are his family. He is

the head of the family. His daughter stated that the
only problem they have is the hospitalization of her
father because of financial problems that arises from it.
They resolve and manage their problems through
constant communication themselves.
I. Sexually – Reproductive Pattern

His daughter said that her father shows his

affection to his family by constantly kissing and
hugging them. The client has three children: two girls
and a boy.
J. Coping – Stress Tolerance Pattern

Before being hospitalized the client experiences

many stressors are brought about by financial factor
and health problems. They are able to cope up by
constantly cooperating with one another.
K. Value – Belief Pattern

Her father does not hear mass on a regular basis

because he believes that God is always in our hearts
and that we don’t need to go to church just to pray. Yet
he believes that being a Catholic is the best way to be
close to God.
 Physical Assessment:
BP: 160/90 PR: 102 Bpm
Temp: 39˚C RR: 38 Bpm
BODY TECHNIQUE NORMAL ACTUAL ANALYSI
PARTS USED FINDINGS FINDING S
1. SKULL Inspection, Proportional The skull is Normal
palpation to the size of normocephalic
the body, and
round with symmetrical to
prominences in the body with
the frontal and prominences in
occipital area, the frontal and
symmetrical in occipital area,
all place symmetrical in
all place
2. SCALP Inspection White, clean, White, no Normal
free from masses, lumps,
masses, lumps, scars, and
3. FACE Inspection Oblong or Oblong. No Not
round or facial normal-
square, or movement is Indicates
heart shaped,, observed. impairment
facial There were of facial
expression presence of nerves
that is acne around which
dependent on his forehead. cause
the mood or paralysis.
true feelings,
no involuntary
muscle,
Symmetric
facial
movements.
4. EYES Inspection Parallel and Dilated pupils -Not
evenly spaced which is black Normal-
symmetrical, in color and Indicates
non- non reacting to altered
5. NOSE Inspection Midline Midline Normal
symmetrical symmetrical
and patent, and patent, no
no discharge. discharge.
With presence
of nasogastric
tube insertion
on the right
nares.
6. EARS Inspection Parallel Parallel Not
symmetrical, symmetrical, normal-
proportional proportional Indicates
to the size of to the size of poor
the head, the head, personal
bean-shaped, bean-shaped, hygiene-
skin is same skin is same inadequate
color as the color as the selfcare
surrounding surrounding primarily
7. MOUTH Inspection Symmetrical, Symmetrical, Normal
gums pinkish in gums slightly
color, lips dark in color
margin is with yellowish
symmetrical, no teeth, lips
lesion and margin is
tenderness, symmetrical, no
without lesion and
involuntary tenderness,
movement without
involuntary
movement
A. SKIN Inspection, Varies from light With uniform Not normal-
palpation to deep brown, deep brown skin The client
from ruddy pink color with has impaired
to light pink, slightly elevated skin integrity
from yellow temperature. with
overtones to Poor skin hyperthermi
olive, generally integrity and a and
uniform skin redness on bony disruptions
temperature prominences. on skin
integrity.
B. HAIR Inspection Thick, silky, Thick, oily with Normal
resilient, free traces of white
from hairs evenly
infestation, distributed
evenly which covers
distributed and the whole scalp
covers whole and free from
scalp. infestation.

C.NAILS Inspection, Convex Long with Normal

palpation curvature convex
smooth curvature
texture, highly smooth texture,
vascular and highly vascular
pink, prompt with bluish to
return of pink pinkish
less than 4 discoloration,
seconds capillary refill
is prompt.
D.NECK Inspection, Symmetrical Symmetrical Normal
REGION palpation and straight, and straight,
no palpable no palpable
lumps, and lumps, and
supple, supple,
trachea is on trachea is on
midline of midline of
neck, and neck, and
spaces are spaces are
equal on both equal on both
sides. sides.
E. LUNGS Auscultation Symmetrical Difficulty of Not
chest breathing normal-
expansion, with breath Indicates
clear breath sounds tachypnea
sounds. (ronchi) primarily
audible even due to
without the hypertensi
F. HEART Auscultation A dynamic Palpitations Not Normal-
pericardium, with elevated indicates
normal rate, heart rate of 115 increase
regular rhythm, bpm. cardiac
no murmur. overload due
to increase
blood
pressure

G.PHERIPER Palpation Symmetrical Symmetrical Normal

AL pulse volume, pulse volume,
full pulsation full pulsation
H. BREAST Inspection, No tenderness, No tenderness, Normal
palpation masses, nodules masses, nodules
and discharge. and discharge.

I. ABDOMEN Inspection, Uniform color, Uniform color, Normal

Auscultation, rounded rounded
Percussion, symmetrical symmetrical
Palpation. contour, audible contour, audible
bowel sounds, bowel sounds,
no tenderness, no tenderness,
liver and liver and
bladder are not bladder are not
palpable palpable
J.MALE Inspection Normal pubic The genitalia Not
GENITALIA hair was not Normal-
distribution is assessed Indicates
noted and free because the Urinary
from
relatives dysfunction
infestation.
Penile lesions,
refused to do (refer to
masses, or so. The patient laboratory
discharges are also has an result).
not indwelling
present.Testes catheter.
is symmetric
without masses
or undue
tenderness. The
left testis may
be slightly
larger and hang
lower than the
right
testis.Inguinal
K. UPPER Inspection Equal size on Immobilization Not normal
AND both sides of of all the the patient is
LOWER the body, no extremities. comatose.
EXTREMITI contractures,
ES deformities and
tenderness,
normally firm,
joints move
smoothly.
Laboratory Test:
BLOOD CHEMISTRY
Test Results Normal Values

Glucose HGT 105 75-115mg/dl

Creatinine 1.7 0.6-1.1mg/dl

Sodium 142 135-140mmol/L

Potassium 3.5 3.5-5.3mmol/L

Uric acid 4.5 3.4-7.0mg/dl

Total Cholesterol 250 <200mg/dl

Triglycerides 133 <200mg/dl

HDL 40.8 40-58.7mg/dl

 BLOOD HEMATOLOGY

Results Normal Values

RBC 8.0 4.5-5.8 x 12/L

WBC 15,900 5000-10000/cumm

Hgb 21 14-18 x 12/L

Hct 0.62 0.42-0.52 x 12/L

Platelet count 300000 150000-450000/cumm

Segmenters 0.66 0.50-0.66

Lymphocytes 0.30 0.20-0.40

Monocytes 0.04 0.02-0.08

Anatomy and Physiology Unoxygenated Blood

Blood Circulation: Superior & Inferior Vena cava

Right Atrium

Tricuspid Valve

Right Ventricle

Pulmonary trunk & pulmonary

Arteries

LUNGS (process f oxygenation)

 Pulmonary Vein

Left Atrium

Bicuspid valve

Left ventricle

Aortic Valve

Aorta

Systemic Circulation
 BRAIN: Cranial Nerves
1. Olfactory: Smell
2. Optic: Visual fields and ability to see
3. Oculomotor: Eye movements; eyelid opening
4. Trochlear: Eye movements
5. Trigeminal: Facial sensation
6. Abducens: Eye movements
7. Facial: Eyelid closing; facial expression;
taste sensation
8. Auditory/vestibular: Hearing; sense of balance
9. Glossopharyngeal: Taste sensation; swallowing
10. Vagus: Swallowing; taste sensation
11. Accessory: Control of neck and shoulder muscles
12. Hypoglossal: Tongue movement
• Cranial Nerves – There are 12 pairs of nerves that originate from
the brain itself. These nerves are responsible for very specific
activities and are named and numbered as follows:
• Olfactory: Smell
• Optic: Visual fields and ability to see
• Oculomotor: Eye movements; eyelid opening
• Trochlear: Eye movements
• Trigeminal: Facial sensation
• Abducens: Eye movements
• Facial: Eyelid closing; facial expression; taste sensation
• Auditory/vestibular: Hearing; sense of balance
• Glossopharyngeal: Taste sensation; swallowing
• Vagus: Swallowing; taste sensation
• Accessory: Control of neck and shoulder muscles
• Hypoglossal: Tongue movement
Cranial Meninges
BRAIN
BRAIN
Non-modifiable Risk PATHOPHYSIOLOGY Modifiable Risk Factors
Factors >HPN
>Advanced Age >Smoking
>Gender >excessive intake of foods
>Heredity high in fats and cholesterol
Triggering Factors
>Sudden extreme emotion

Cerebral aneurysm Arteriovenous

rupture malformation

Bleeding into the brain tissue

and subarachnoid space

Blood Clots in the

Subarachnoid Space
Blood supply interruption Brain Compression

S/S:
Tissue Necrosis >Severe Headache Increase Intracranial
>Drowsiness Pressure
>Loss of consciousness
Neuronal Death

Regional Paralysis Epileptic Seizure:

increase intraocular
pressure= blindness
Total Paralysis

coma

Death
 Drug study 1

Medication Classification Indication Contraindicatio Side effects Adverse effects Nursing

/ Action n consideration
Generic name: Inhibits Treatment of Hypersensitivity Patients Dizziness, Use caution in
nifedipine calcium ion vasospatic, , cardiovascular withdrawn flushing, severe aortic
Brand name: influx across angina, shock, from headache, stenosis or severe
Calcibloc all chronic combination blockers hypotension hepatic
membrane stable with while peripheral impairment
Route: oral during angina, rifampicine taking edema, Assess potential
Dosage: 180mg cardiac hypertension contraindicated nifedifine tachycardia for interactions
Frequency: depolarizatio (sustained- in unstable may and palpitation with other
once a day n, produces released angina and experience pharmacological
relaxation of tablets only. after resent MI increase agents or herbal
coronary severe angina products patients
vascular hypotension, is taking that
smooth with systolic may increase
muscle and pressure less risk of
peripheral than 90 mmHg hypotension and
vascular decompensate toxicity
smooth heart failure Monitor blood
muscle, pregnancy and pressure and
dilates lactation pulse before
coronary therapy, during
arteries, dose
increase
myocardial
oxygen
filtration and
periodically during
therapy monitor
ECG periodically
during prolonged
therapy
Assess therapeutic
effectiveness and
adverse reaction
Assess location,
duration intensity,
precipitating factor
of patients angina
pain
 Drug study 2

Medication Classification/ Indication Contraindication Side effects Adverse effects Nursing

Action consideration
Generic name: Increases the Adjunct in the Hypersensitivity , CNS: headache, Monitor vital
Mannitol osmotic treatment of anuria, confusion. signs, urine
Brand name: pressure of acute oliguric dehydration, output, CVP, and
Osmitrol the renal failure, intracranial EENT: blurred pulmonary artery
Route: IV glomerular adjunct in the bleeding. vision, rhinitis pressure prior to
filtrate, treatment of and hourly
Dosage: thereby edema, throughout
Adult 0.25-2 g/kg inhibiting redunction of CV: transient administration.
as 15 to 25% reabsorption intraocular volume Assess patient for
solution over 30 of water and pressure, to expansion, signs and
to 60 min. electrolytes. promote the tachycardia, symptoms of
Children 1-2 g/kg excreation of chest pain, dehydration or
(30 – 60 g/m2)as certain toxic congestive heart signs of fluid over
a 15 to 20 substances. failure, load.
solution 0ver 30 – pulmonary
edema. Assess patient for
60% anorexia, muscle
Frequency: weakness,
4x daily GI: thirst, numbness,
nausea, tingling, confusion
vomiting and excessive
thirst.
GU: renal
failure, urinary
retention.
Monitor neurologic
status and
intracranial
pressure readings
in patient receiving
this medication to
decrease cerebral
edema.
 Drug study 3

Medication Classification Indication Contraindicatio Side effects Adverse effects Nursing

/ Action n consideration
Generic name: Inhibits Hypertension Sick sinus CHF, Palpitations, Assess cardio
Amlodipine influx of , chronic syndrome; hepatic peripheral respiratory
Brand name: calcium ion stable second-or-third- impairmen edema, status. Angina
across cell angina, degree t, caustious syncope, pain, B/P pulse,
Amvasc, membranes vasospatic artrioventicular use is tachycardia, respiration, ECG
norvasc to produce angina block exept with required bradycardia,
Route: relaxation of a functioning arrythmias, Assess hydration
Dosage: coronary pacemaker ventricular and fluid volume
5 mg vascular asystoles, status, input and
Frequency: smooth headache, output ratio,
muscle dizziness, presence of
Once daily (dilatation of lightheadednes edema, distended
coronary s, fatigue, neck veins, luck
arteries) lethargy, crackles,
decrease somnolence, adequate pulses
peripheral dermatitis,rash and skin turgor.
vascular pruritus,
resistance of uticaria,nausea
smooth , abdominal
muscle discomfort,
(decrease cramps,
blood dyspepsia,
pressure) shortness of
breath,
and increases dyspnea, Monitor liver
myocardial wheezing, function ALT, AST,
oxygen flushing, bilirubin
delivery in sexual Monitor if platelet
patients with difficulties, count is less than
vasospatioc muscle 150,000/mm, drug
angina. cramps, pain is usually
or discontinued and
inflammation another drug
started.
 Drug study 4

Medication Classification/ Indication Contraindicatio Side Adverse Nursing

Action n effects effects consideration

Generic name: Inhibits the •Mild to Previous GI: hepatic •Advise patient
Acetomenophen synthesis of moderate hypertensive necrosis to take
Brand name: prostaglandin pain Product DERM: rash, medication
that may serve •Fever containing urticaria. exactly as
Aminofen as mediators of directed and not
alcohol,
Route: pain and fever. aspartame, to take more
IV saccharin, sugar than the
Dosage: Therapeutic or tartrazine. recommended
325-1000mg effects. amount.
every 4 to 6 hrs •Analgesic (due Severe and
needed to peripheral permanent liver
prostaglandin damage may
inhibitors) result from
prolonged use or
•Antipyresis high doses of
(lowers fever); acetomenophe.
due to
inhibitors of Adult should not
prostaglandin take
in the CNS acetomenophen
longer than 10
No significant days and
anti children longer
•Advise the patient to
consult the physician if
discomfort or fever is not
relieved by routine
dosages of this drug or if
fever is greater than 39.5
(103 F) or lasts longer
than 3 days
 Nursing Care Plan One
ASSESSME DIAGNOS OBJECTI PLANNIN INTERVENTIO RATIONA EVALUATIO
NT IS VE G N LE N
Objective Ineffective After four Plan ways Position head To open or After four
cues: airway hours of on how to midline with maintain hours of
clearance nursing reduce flexion airway to nursing
•Clavicular related to interventi congestion appropriate for the client. intervention
retained on the on airway. condition. the client air
•Breaking mucus client way clearance
•Rhonchi To clear
secretion airway Oropharyngial airway is cleared.
breathing due to clearance
sound suctioning (as when
absence of will be needed) secretions
•Increase cough cleared. are
respiratory reflex. blocking on
rate of 36 to airway.
38 bpm Scientific Elevate head of
Explanatio the bed and To decrease
n: Inability change position the
to clear every 2 hrs. pressure on
secretions the
or diaphragm.
obstruction Increased fluid
from the intake at least
Auscultate To maitain
breath souds and status and note
assess air progress
movement
 Nursing Care Plan Two
ASSESSMEN NURSING OBJECTI PLANNING NURSING RATIONALE EVALUATI
T DIAGNOSIS VE INTERVENTION ON
Subjective Cues: Hyperthermia >after 2 >Plan >Identify under >To assess causative >after 2
>”tatlong araw related to hours of techniques in lying cause factors to the clients hours of
na siyang inflammation of nursing which the fever thus nursing
nilalagnat” as cerebral tissue as interventions temperature formulation of intervention
verbalized by evidence by the client’s of the client appropriate nursing the client’s
the relatives. elevated body temperature will decrease intervention. temperature
Objective Cues: temp. will decrease to a normal >Heat loss by is decreased
to a normal rage. evaporation and to a normal
>elevated body range. range
temp of 39˚C Scientific EXP: >Promote surface conduction
Body temperature cooling by means
>flushing skin of tepid sponge
>warm to touch elevated above >Heat loss by
normal range, bath convection.
>increase RR because of body’s >Establish cool
with a rate of 38 response to environment by
Bpm inflammation opening air vents
>diaphoresis from hemorrhage and window panes >to avoid further
that result from >Advise relatives increase of clients
ruptured cerebral not to cover the temperature.
artery. client with a
blanket, and use
less restrictive
clothing’s
> Administer > For immediate
antipyretics through alteration of body
IV as prescribed. temperature
 Nursing Care Plan Three
ASSESSME DIAGNOSIS OBJECTIV PLANNIN INTERVENTI RATIONAL EVALUATI
NT E G ON E ON
Objective >Risk for >After 3 >Plan >Note for > To assess After two
Cues: impaired skin hour s of strategies general aggravating hours of
>reddened Integrity nursing on how to debilitation, factor to skin nursing
skin related to intervention eliminate reduced breakdown intervention
>poor skin physical the client the risk for mobility, and make the
turgor immobilizatio relatives will impaired changes in skin appropriate possibilities
n. identify risk skin and muscle intervention for impaired
>immobility factors for mass, poor to it. skin integrity
integrity.
>friction impaired nutritional of the client
Scientific
Explanation: skin status and is eliminated.
integrity , problems of self
At risk for verbalize care
skin being understandi
potentially > Maintain > To prevent
ng of strict skin skin
vulnerable to therapy
breakdown hygiene, using irritation
regimens mild non-
because of and
immobilizatio detergent soap,
demonstrate drying gently
n behaviors and thoroughly.
and and lubricating
techniques with lotion
to prevent
>Instruct the >To reduce
relative to turn tissue pressure
the patient every and prevent
two hours pressure sore.

> Avoid friction > To prevent a

when changing shearing force
position on the skin.

>Provide >To increase

protection by circulation and
use of eliminate
pads,pillows, excessive tissue
foam mattress. pressure.

>Observe for >Reduces

reddened or likelihood of
blanched areas progression to
and give proper skin breakdown.
management if
there is any.
 Discharge Plan

M >Nifedipine must be given 10mg once a day by sublingual as

prescribed.
>Instruct the relative to follow medication regimen.

>Encourage the relative to do some exercises like a passive range of

E motion in affected and unaffected parts of the body of the client.

T > Educate & instruct the family to monitor the blood pressure and
pulse rate before administering medication.
 >Inform the relative the importance of proper hygiene of the
patient from head to toe.
H >regular inspection of the diaper of the patient and change if
there a presence of fecal material, urine or even redness that
would lead to skin rashes.
>Educate and instruct the relatives on how to feed the client
through nasogastric tube.
>Instruct them to turn the client every 2 hrs to avoid pressure
sores.

>Inform the family of the patient to have a regular check-up for

O the continuity of treatment.
>Instruct the family of the patient to monitor if there is any
sudden change to the patient and report immediately.

>Instruct the relative to feed the client on time with nutrition

D food that is low in sodium, low in cholesterol, low in fat and give
citrus fruits, moderate in fluid intake and increase fiber diet to