INTRODUCTION

A stroke is a term used to describe neurologic changes caused by an interruption

in the blood supply to a part of the brain. A stroke is caused by the interruption of the

blood supply to the brain, usually because a blood vessel bursts or is blocked by a clot.

This cuts off the supply of oxygen and nutrients, causing damage to the brain tissue.

The most common symptom of a stroke is sudden weakness or numbness of the

face, arm or leg, most often on one side of the body. Other symptoms include: confusion,

difficulty speaking or understanding speech; difficulty seeing with one or both eyes;

difficulty walking, dizziness, loss of balance or coordination; severe headache with no

known cause; fainting or unconsciousness. The effects of a stroke depend on which part

of the brain is injured and how severely it is affected. A very severe stroke can cause

sudden death. The two major types of stroke are ischemic and hemorrhagic. Ischemic

stroke is caused by a thrombotic or embolic blockage of blood flow to the brain. Bleeding

into the brain tissue or the subarachnoid space causes a hemorrhagic stroke. Ischemic

strokes account for approximately 83% of all strokes. The remaining 17% of strokes are

hemorrhagic.

Cerebrovascular disorders are the third leading cause of death in the United States

and account for approximately 150,000 mortalities annually. An estimated 550,000

people around the world experience a stroke each year. Stroke is both the leading cause

of adult disability and the primary diagnosis for long term care. In the UK, it is the

second most common cause of death, the first being heart attacks and third being cancer.

It is the number two cause of death worldwide and may soon become the leading cause of
death worldwide. Stroke is also the second leading cause of death in the Philippines with

a total of 51,680 according to DOH(site reference). Along with this are 37, 092 who

survived with it. There are millions of stroke survivors living with varying degree of

disability in the world. Along with a high mortality rate, strokes produce significant

morbidity in people who survive them. Of the stroke survivors, 31% require assistance

with self care, 20% require assistance with ambulating, 71% have some impairment in

vocational ability up to 7 years following the stroke, and 16% are institutionalized.

We decided to use this as a subject for our case study because as what we all

know this kind of illness is said to be a silent killer if prompt medical attention is unmet.

That is why we want to know the root cause of such disease in order for us to know how

we could intervene and play our role as a nurse. We believe that by studying this case we

will gain more information and knowledge about the disease and will lead us to a certain

perception as to how we will manage and care if ever we will experience again patients

with the same disease.

should be all about study

 OBJECTIVES

General Objectives:

To conduct a thorough and comprehensive study about Mr. Ek’s disease

according to data that was gathered by conducting a series of interviews and through the

use of data gathered from extensive research.

Specific Objectives:

• To organize our patient’s data for the establishment of good background information

• To show the family health history as well as the history of past and present illness for the

knowledge of what could be the predisposing factors that might contribute to the patient’s

illness

• To present the Family’ Genogram containing information that will help out in tracing

hereditary risk factors

• To trace the psychological development of our patient through analysis of different

developmental theories with comparison to the patient’s data

• To give different definitions of the complete diagnosis of our patient for better

understanding of unfamiliar terms

• To present the data from the Physical assessment performed on our patient for a good

interview of his over-all health

• To elaborate on the anatomy and physiology of different organs involved and affected

during CVA

• To establish whether several factors, signs and symptoms are present or absent in our

patient
• To organize a flow chart showing the pathophysiology of CVA for a clear visualization

of how CVA affects a person

• To list the different orders of the physicians assigned to our patient together with their

rationale for a general knowledge of what consists of the medical management for CVA

• To present the different results of our patient’s diagnostic exams together with

comparisons of normal values for the understanding of what changes during the disease

• To present the different drugs used by our patient to have a better understanding of its

functions and purposes

• To analyze the different nursing theories that can be applied to our patient

• To come up with the different Nursing Care Plans applicable to our patient

• To formulate an appropriate discharge plan

• To create a reasonable prognosis basing on the gathered data

• To have our over-all Conclusion and recommendations about the case study

• To gather all the references used upon making this case study

Patients’s Data

Patient’s Code name: Mr. Eks

Age: 48 y.o.
Birthdate: April 21,1961

Birth place: Davao Oriental

Sex: Male

Nationality: Filipino

Religion: Roman Catholic

Civil Status: Married

Occupation:

Ward: Male Ward

Date of Admission: April 20, 2009

Time of Admission: 12:30 pm

Vital Signs on Admission:

BP:

RR:

Temp:

PR:

Mode of Arrival: Stretcher

Admitting Doctor: Dr. Mary Joy Bayocol, MD

Chief Complaint: Body Weakness

Admitting Diagnosis:

Final Diagnosis: Cerebrovascular accident, Infarct, Left middle cerebral artery

Family Background

Mr. Eks, a 48-year old male, was born in Davao Oriental on April.21, 1961. He is

currently residing at Cateel, Davao Oriental. They are 6 in the family including his
parents. He is the third child among the four children. Our patient was completely

immunized since he received the needed immunizations before he reached 1 year old.

He finished elementary and high school at Maryknoll School at Cateel, Davao

Oriental. Our patient decided to study in college at Manila, but sad to say they said that

he was tired of going to school and decided to stop.

Mr. Eks has been married for 9 years with Mrs. Eks. Throughout their marriage,

they had 2 offsprings. Their eldest is 7 years old and their youngest is 6 years old and

they are currently studying at Maryknoll elementary, Davao Oriental. According to Mrs.

Eks, she decided to work on abroad at Israel to meet their families’ needs. Mr. Eks and

his 2 children are currently living in his nephew’s house at Cateel.

Upon interview with Mrs. Eks, Mr. Eks was recommended by his neurosurgeon in

Cateel, Dr. Aguhitas, to travel in Limso for the specialization of his illness which is

“stroke”.

Lifestyle:

Through Mr. Eks wife, we were able to formulate Mr. Eks activities during his

day before his illness took place. She said that Mr. Eks usually wakes up @ 4am and eats

breakfast @ 7 am. After eating, he uses his bicycle as his mode of transportation in going

to his farm. His travel time going there is 30 mins and spends his entire day in the farm.

He goes home at around 5pm, but sometimes he stops by at his friend’s house to have a

drink (alcohol beverages). In a week, he drinks twice or thrice but does not smoke.
Diet:

Mrs. Eks verbalized that they usually have vegetables, fish and rice for their meal.

However, they feel eating roasted pig whenever they like it. Mr. Eks likes fruits for

dessert like mango, papaya and watermelon.

History of Past Illness:

Mr. Eks Mother said that at the age of 17, he underwent cardiac surgery at the

Philippine Heart Center in Manila. It was due to his Congenital Heart Disease which he

inherited from his mother. Before the heart surgery took place, Mr. Eks experienced

serious chest pain then they sought for medical attention and was diagnosed of having

Congenital Heart Disease. Mrs. Eks mother said that after the surgery Mr. Eks cannot

tolerate heavy workload and stress but his condition improved after how many years of

complying with the recommended health regimen.

On October 4,2008, Mr. Eks wife said that he had his first mild stroke but it didn’t

affect his health that much. He resumed doing his activities of daily living the day after

the mild stroke.

History Of Present Illness:

April 16,2009 at Cateel, Mr. Eks spends his usual activities for the day. He went

to the farm for his work then came backto poblacion to visit a friend. He drinks 1Liter of
sprite and sang 1 song from the videoke. While singing, he suddenly collapsed and was

brought and admitted to the nearest hospital. Due to lack of facilities, he was referred by

Dr. Aguhitas to Ricardo Limso Hospital or April 20,2009. Mr. Eks experienced visual

disturbance @ his right eye because he is having hemiparesis in which his right side of

his body is weak.

Effect to the family

According to Mrs. Eks, his husband’s condition had greatly affected their family.

At first they had a hard time accepting his condition but they had eventually learned to

accept it. Emotionally, it affected them because they know that Mr. Eks' condition is

serious and that there is always a possibility that they would lose him.

Financially, it had affected them because of his hospitalizations, medications and

other treatments he had to undergo. However, their family members including other

relatives, are always ready to help/support them financially and emotionally.

DEVELOPMENTAL DATA
 Theorist Theory Stage Result ands
Justification
Erik Erikson’s Erik Erikson Integrity Vs. Despair Due to Mr. Eks’

Psychosocial theorized that (45 years old and inability to

Theory of
Development development is a above) verbalize, the group

lifelong process A person who can look has opted to rely on

and does not end back on good times with the verbalizations of

with the cessation gladness, on hard times his significant

of adolescence. with self – respect, and others.

Just as physical on mistakes and regrets

growth patterns with forgiveness, will Mr. Eks has

can be predicted, find a new sense of positively achieved

certain integrity and a readiness this stage of

psychosocial for whatever life or development. His

tasks must be death may bring. wife said that his

mastered in each A person caught up in husband had

developmental old sadness, unable to mentioned in one of

stage. The greater forgive themselves or their conversations

the task others for perceived that he is happy and

achievement, the wrongs, and dissatisfied contented with what

healthier the with the life, they’ve he and his family

personality of the led, will easily drift into have even if there

person however, depression and despair. have been a lot of

failure to achieve A positive outcome in struggles in their

a task influences this stage is achieved if lives. His mother

the person’s the person gains a self said that she saw in

ability to achieve fulfillment of about life his son how he was

the next task. and a sense of unity able to handle the

within himself and problems that came

others. That way, he can his way and that she

 Definition of Complete Diagnosis

Cerebrovascular Accident

- A sudden, nonconvulsive focal neurologic deficit.

Reference: Pathophysiology (the biologic basis for disease in Adults and Children) 2nd

Ed. By McCance and Huether.

Cerebrovascular Accident
 - An infarction of brain tissue that results from lack of blood. Tissue necrosis may

be an outcome of total occlusion of a cerebral blood vessel by atheroma or

embolus, or it may be the consequence of a ruptured cerebral vessel.

Reference: Pathopysiology for the Health Professions by Barbara E. Gould

Cerebrovascular Accident

- Is a sudden impairment of cerebral circulation in one or more of the blood vessels

supplying the brain. CVA interrupts or diminishes oxygen supply and commonly

causes serious damage or necrosis in brain tissues.

Reference: Handbook of Medical-Surgical Nursing 3rd Ed. By McCann, Springhouse

Cerebrovascular Accident

- The sudden death of some brain cells due to lack of oxygen when the blood flow

to the brain is impaired by blockage or rupture of an artery to the brain. A CVA is

also referred to as a stroke.

Reference: http://www.medterms.com/script/main/art.asp?articlekey=2676

Cerebrovascular Accident

Also known as a stroke, is an acute neurologic injury whereby the blood supply to a part

of the brain is interrupted, either by a clot in the artery or if the artery bursts. The result is
that the part of the brain perfused by that artery no longer can receive oxygen carried by

the blood and it dies (becomes necrotic) with cessation of function from that part of the

brain. In addition to tissue death, hemorrhages also cause damage from physical

impingement of blood on the brain tissue. Stroke is a medical emergency and can cause

permanent neurologic damage or even death if not promptly diagnosed and treated. It is

the third leading cause of death and adult disability in the US and industrialized European

nations.

Reference: http://psychology.wikia.com/wiki/Cerebrovascular_accident

Physical assessment

Patient’s Name: Mr. Eks

Age: 48 y.o.

Sex: Male

Ward: Male Ward (Limso Hosp.)

General Survey:
 Our patient, Mr. Eks was assessed on April 30, 2009 at 5:00pm. He was received

lying on bed awake. He has an ongoing IVF of # 15 PLR 1 liter regulated @20

drops/min. infusing well at R Basilic vein at 900cc level. With Nasogastric inserted @ R

nostril, patent with distal end closed. He has an endomorphic body structure. He has a

Right-sided body weakness.

Vital signs:

5:00 pm

BP- 130/90 mmHg

PR- 68 bpm

RR- 25 bpm

Temp.- 38.1 °C

Skin

Skin was generally uniform in color- tan, has a smooth texture and has a good

skin turgor as skin goes back to its previous state after being pinched and with a capillary

refill of 2 seconds. Nails were properly trimmed and no traces of dirt were noted. Upon

touching, the skin on his forearm is warm.

Head
 Our patient’s head is normocephalic. Presence of hair was noted in the head and

in the upper and lower extremities. He has black hair and evenly distributed. Upon

observation, there is a presence of dandruff noted. Lesions, bleeding and bruises were not

seen upon inspection.

Eyes

The sclera is moist and slightly yellowish in color. The iris appears to be black on

both eyes. He has an isocoric pupil reaction of 2mm round and reactive to light and

accommodation. Both eyes move in unison, no signs of scratches and discharges on both

eyes noted. Upon interviewing with his wife, she said that he can see both near and far

objects by not having difficulties in reading in far and near texts.

Ears

The shape of the pinnaes are oval and with no discharges noted. Upper margin of

the pinnaes are in line with the outer canthi of the eyes. Ears are firm and non-tender.

Signs of lesions, lacerations, swelling and bruises were not seen upon inspection. He was

able to response when instructed to do so, which reveals that he does not have any

hearing problems.

Nose

With Nasogastric Tube noted, inserted @ right nostril, patent with distal end

closed. External surface of the nose is smooth and oily. Nasolabial folds are symmetrical.
Nostrils are also symmetrical with no flaring and discharges noted. Nasal hairs are

present upon inspection. Nasal septum is not deviated. Both nostrils are patent. No signs

of tenderness were noted.

Mouth

Outer lips are symmetrical in contour. Upper and lower lips are brown in color.

No lesions or edema were noted. Teeth were not complete. Buccal mucosa appears

pinkish and smooth. Tongue is in midline and pinkish in color. Gums are slightly brown

in color, no bleeding or ulcerations noted. Tonsils were not inflamed and uvula is also in

midline. Patient was on diet as tolerated and was observed to eat crackers with easy

mastication and no dysphagia. . Patient was on oral feeding of 250cc and flushed with

water of 250cc via NGT every 3hours with aspiration precaution. With gelatin cubes

PRN/orem to exercise his mastication process.

Neck

The neck of our patient can move easily without any difficulty, which includes

right and left lateral, right and left rotation, flexion except hyperextension. Neck can

properly support the head. No signs of enlargement and masses on the thyroid. Carotid

pulse is palpable. No signs of swelling or enlargement of the lymph nodes. No

deformities noted.
Chest and Lungs

Chest muscle expansion during inspiration and relaxation during expiration are

symmetrical and painless. A Scar was noted in midline with the sternum until to the

xiphoid process indicating that he underwent an open heart surgery during his teenage

life. There were no other signs of scars and lesions were noted. He was not in respiratory

distress. Respiratory rate is 25 cycles per minute and rhythm was irregular. Upon

auscultation, presence of crackles were noted indicating he has a productive cough.

Abdomen

Abdomen is soft, non-tender and globular in shape. There were no scars and

lesions noted upon inspection. No discharges were noted on his umbilicus. Bowel sounds

are normoactive with 11 sounds counted within one minute.

Genito-Urinary

With condom catheter attached to urobag draining with yellow amber colored

urine and diaper in case of defecation. His total urine output for 8 hours was about 640cc

and was able to defecate six times with an output of approximately 1500cc.

Upper extremities
 Patient’s upper limbs, shoulders and arms were symmetrical. No tenderness noted

on the bones of the wrist and fingers. No deformities and swelling noted. With Right

sided hemiparesis, he couldn’t move his right shoulder and arm. The patient has a weak

grip in the Left hand when he was asked to squeeze one of the student nurse’s hands. No

structural deviations noted. Mr. Eks was undergoing venoclysis with IVF of # 15 PLR 1

liter regulated @20 drops/min. infusing well at R Basilic vein at 900cc level.

Lower Extremities

Both legs of the patient are symmetrical. The Left leg can stretch, flex, rotate,

extend and bend without any difficulty except for the Right leg. No signs of deformities,

lesions, lacerations, bruises and bleeding were seen upon inspection. Patient has difficulty

ambulating because of right sided body weakness.

Neurological Assessment

Pupil

Size (left): 2mm

(right): 2mm

Reaction (right): brisk

(left): brisk

Motor
 Handgrip (left): Strong

(Right): Absent

Leg Movement (left): Moderate

(Right): Absent

Level of consciousness

Eye opening: 4 (spontaneous)

Best verbal response: 2 (incomprehensible)

Best motor response: 6 (Obeying)

Reactive Level Scale: 1 (alert, fully conscious)

Glasgow Coma Scale: 12

Anatomy and Physiology

Human Brain
 The anatomy of the brain is complex due its intricate structure and function. This
amazing organ acts as a control center by receiving, interpreting, and directing sensory
information throughout the body. There are three major divisions of the brain. They are
the forebrain, the midbrain, and the hindbrain.

Anatomy of the Brain: Brain Divisions

The forebrain is responsible for a variety of functions including receiving and

processing sensory information, thinking, perceiving, producing and understanding
language, and controlling motor function. There are two major divisions of forebrain: the
diencephalon and the telencephalon. The diencephalon contains structures such as the
thalamus and hypothalamus which are responsible for such functions as motor control,
relaying sensory information, and controlling autonomic functions. The telencephalon
contains the largest part of the brain, the cerebral cortex. Most of the actual information
processing in the brain takes place in the cerebral cortex.

The midbrain and the hindbrain together make up the brainstem. The midbrain is the
portion of the brainstem that connects the hindbrain and the forebrain. This region of the
brain is involved in auditory and visual responses as well as motor function.
The hindbrain extends from the spinal cord and is composed of the metencephalon and
myelencephalon. The metencephalon contains structures such as the pons and
cerebellum. These regions assists in maintaining balance and equilibrium, movement
coordination, and the conduction of sensory information. The myelencephalon is
composed of the medulla oblongata which is responsible for controlling such autonomic
functions as breathing, heart rate, and digestion.

• Prosencephalon - Forebrain
• Mesencephalon - Midbrain
o Diencephalon
o Telencephalon
• Rhombencephalon - Hindbrain
o Metencephalon
o Myelencephalon

Anatomy of the Brain: Structures

The brain contains various structures that have a multitude of functions. Below is a list of
major structures of the brain and some of their functions.

Basal Ganglia

• Involved in cognition and voluntary movement

• Diseases related to damages of this area are Parkinson's and Huntington's

Brainstem

• Relays information between the peripheral nerves and spinal cord to the upper
parts of the brain
• Consists of the midbrain, medulla oblongata, and the pons

Broca's Area

• Speech production
• Understanding language

Central Sulcus (Fissure of Rolando)

• Deep grove that separates the parietal and frontal lobes

Cerebellum

• Controls movement coordination

• Maintains balance and equilibrium

Cerebral Cortex
 • Outer portion (1.5mm to 5mm) of the cerebrum
• Receives and processes sensory information
• Divided into cerebral cortex lobes

Cerebral Cortex Lobes

• Frontal Lobes -involved with decision-making, problem solving, and planning

• Occipital Lobes-involved with vision and color recognition

• Parietal Lobes - receives and processes sensory information

• Temporal Lobes - involved with emotional responses, memory, and speech

Cerebrum

• Largest portion of the brain

• Consists of folded bulges called gyri that create deep furrows

Corpus Callosum

• Thick band of fibers that connects the left and right brain hemispheres

Cranial Nerves

• Twelve pairs of nerves that originate in the brain, exit the skull, and lead to the
head, neck and torso

Fissure of Sylvius (Lateral Sulcus)

• Deep grove that separates the parietal and temporal lobes

Limbic System Structures

• Amygdala - involved in emotional responses, hormonal secretions, and memory

• Cingulate Gyrus - a fold in the brain involved with sensory input concerning
emotions and the regulation of aggressive behavior

• Fornix - an arching, fibrous band of nerve fibers that connect the hippocampus to
the hypothalamus

• Hippocampus - sends memories out to the appropriate part of the cerebral

hemisphere for long-term storage and retrievs them when necessary

• Hypothalamus - directs a multitude of important functions such as body

temperature, hunger, and homeostasis
 • Olfactory Cortex - receives sensory information from the olfactory bulb and is
involved in the identification of odors

• Thalamus - mass of grey matter cells that relay sensory signals to and from the
spinal cord and the cerebrum

Medulla Oblongata

• Lower part of the brainstem that helps to control autonomic functions

Meninges

• Membranes that cover and protect the brain and spinal cord

Olfactory Bulb

• Bulb-shaped end of the olfactory lobe

• Involved in the sense of smell

Pineal Gland

• Endocrine gland involved in biological rhythms

• Secretes the hormone melatonin

Pituitary Gland

• Endocrine gland involved in homeostasis

• Regulates other endocrine glands

Pons

• Relays sensory information between the cerebrum and cerebellum

Reticular Formation

• Nerve fibers located inside the brainstem

• Regulates awareness and sleep

Substantia Nigra

• Helps to control voluntary movement and regualtes mood

Tectum

• The dorsal region of the mesencephalon (mid brain)

Tegmentum

• The ventral region of the mesencephalon (mid brain).

Ventricular System - connecting system of internal brain cavities filled with

cerebrospinal fluid

• Aqueduct of Sylvius - canal that is located between the third ventricle and the
fourth ventricle

• Choroid Plexus - produces cerebrospinal fluid

• Fourth Ventricle - canal that runs between the pons, medulla oblongata, and the
cerebellum

• Lateral Ventricle - largest of the ventricles and located in both brain hemispheres

• Third Ventricle - provides a pathway for cerebrospinal fluid to flow

Wernicke's Area

• Region of the brain where spoken language is understood

Motor Functions

The motor system of the brain and spinal cord is responsible for maintaining the
body’s posture and balance; as well as moving the trunk, head, limbs, tongue, and eyes:
and communicating through facial expressions and speech. Reflexes mediated through
the spinal cord and brainstem is responsible for some body movements. They occur
without conscious thought. Voluntary movements, on the other hand, are movements
consciously activated to achieve a specific goal, such as walking or typing. Although
consciously activated, the details of most voluntary movements occur automatically.
After walking begins, it is not necessary to think about the moment-to-moment control of
every muscle because neural circuits in the reticular formation automatically control the
limbs. After learning how to perform complex tasks, such as typing, they can be
performed relatively automatic.

Voluntary movements result from the stimulation of upper and lower motor
neurons. Upper motor neurons have cell bodies in the cerebral cortex. The Axons of
upper motor neurons from descending tracts that connects to lower motor neurons. Lower
motor neurons have cell bodies in the anterior horn of the spinal cord gray matter or in
cranial nerve nuclei. Their axons leave the central nervous system and extend through
spinal or cranial nerves to skeletal muscles. Lower motor neurons are the neurons
forming the motor units.

Motor areas of the cerebral cortex

The motor areas are located in both hemispheres of the cortex. They are shaped like a
pair of headphones stretching from ear to ear. The motor areas are very closely related to
the control of voluntary movements, especially fine fragmented movements performed by
the hand. The right half of the motor area controls the left side of the body, and vice
versa.

Two areas of the cortex are commonly referred to as motor:

• Primary motor cortex, which executes voluntary movements

• Supplementary motor areas and premotor cortex, which select voluntary
movements.

In addition, motor functions have been described for:

• Posterior parietal cortex, which guides voluntary movements in space

• Dorsolateral prefrontal cortex, which decides which voluntary movements to
make according to higher-order instructions, rules, and self-generated thoughts.

Descending tracts

The most important descending spinal tract originates in the cerebral cortex and is called
the corticospinal tract (see Figure 1-5). The other major descending spinal tracts worth
mentioning are: the tectospinal tract arising from the superior colliculus, the rubrospinal
tract arising from the red nucleus in the mid-brain, the vestibulospinal tract with its nuclei
located in the floor of the fourth ventricle, and the reticulospinal tract arising from the
reticular formation in the pons and the medulla. The cortico-bulbar tract which is
associated with cranial nerves will not be described in this review of neuroanatomy as it
is not prominently employed in the treatment of patients.
1. The corticospinal system (pyramidal system)

The corticospinal tract supplies impulses to most of the voluntary muscles. It originates in
the precentral gyrus of the cerebral cortex (area 4). The axons pass through the internal
capsule and descend to the mid-brain where they form the crus cerebri (basis pedunculi).
In the medulla oblongata, 80 to 90 percent of the fibers decussate to the opposite side and
descend in the spinal cord where they form the lateral corticospinal tract. In the spinal
cord, the axons of the lateral corticospinal tract are located internal to the posterior
spinocerebellar tract and posterior to the lateral spinothalamic tract.

The lateral corticospinal tract irradiates branches at all levels of the spinal cord. The
fibers enter the gray matter where they synapse in the ventral horn with second-order
neurons. The latter emerge from the spinal cord in the ventral spinal roots and supply the
voluntary muscles through the peripheral nerves.

The remainder of the corticospinal tract which does not cross over in the medulla
oblongata divides into two separate tracts: the anterior corticospinal tract and the
anterolateral corticospinal tract. The axons of the anterior corticospinal tract descend
uncrossed into the spinal cord. They occupy an antero-medial position in the anterior
white commissure and are contiguous to the anterior median fissure. Most of the fibers of
the anterior corticospinal tract descend to the upper cervical spine where they cross in the
anterior white commissure. The fibers enter the gray matter where they synapse in the
ventral horn with second-order neurons.
The anterolateral corticospinal tract is the smallest of the three descending tracts. The
fibers descend in the lateral funiculus and remain uncrossed in the entire course of the
tract. The axons of the anterolateral corticospinal tract synapse in the ventral horn with
second-order neurons. It should be emphasized that the pyramidal or voluntary muscle
system is made of a two-neuron system. The neurons of the corticospinal tracts leaving
the precentral gyrus and descending in the spinal cord to terminate their course in the
ventral horn are called upper motor neurons. The second-order neurons leaving the spinal
cord to supply the voluntary muscles are called lower motor neurons. The distinction
between upper and lower motor neurons paralysis is important in clinical neurology.

Basal nuclei

The basal nuclei are a group of functionally related nuclei. Two primary nuclei are the
corpus striatum, located deep within the cerebrum, and the substantia nigra, a group of
darkly pigmented cells located in the midbrain.
 Anatomy of cerebral circulation

Arterial supply of oxygenated blood

Four major arteries and their branches supply the brain with blood. The four arteries are
composed of two internal carotid arteries (left and right) and two vertebral arteries that
ultimately join on the underside (inferior surface) of the brain to form the arterial circle of
Willis, or the circulus arteriosus.

The vertebral arteries actually join to form a basilar artery. It is this basilar artery that
joins with the two internal carotid arteries and their branches to form the circle of Willis.
Each vertebral artery arises from the first part of the subclavian artery and initially passes
into the skull via holes (foramina) in the upper cervical vertebrae and the foramen
magnum. Branches of the vertebral artery include the anterior and posterior spinal
arteries, the meningeal branches, the posterior inferior cerebellar artery, and the
medullary arteries that supply the medulla oblongata.

The basilar artery branches into the anterior inferior cerebellar artery, the superior
cerebellar artery, the posterior cerebral artery, the potine arteries (that enter the pons), and
the labyrinthine artery that supplies the internal ear.

The internal carotids arise from the common carotid arteries and pass into the skull via
the carotid canal in the temporal bone. The internal carotid artery divides into the middle
and anterior cerebral arteries. Ultimate branches of the internal carotid arteries include
the ophthalmic artery that supplies the optic nerve and other structures associated with
the eye and ethmoid and frontal sinuses. The internal carotid artery gives rise to a
posterior communicating artery just before its final splitting or bifurcation. The posterior
communicating artery joins the posterior cerebral artery to form part of the circle of
Willis. Just before it divides (bifurcates), the internal carotid artery also gives rise to the
choroidal artery (also supplies the eye, optic nerve, and surrounding structures). The
internal carotid artery bifurcates into a smaller anterior cerebral artery and a larger middle
cerebral artery.

The anterior cerebral artery joins the other anterior cerebral artery from the opposite side
to form the anterior communicating artery. The cortical branches supply blood to the
cerebral cortex.

Cortical branches of the middle cerebral artery and the posterior cervical artery supply
blood to their respective hemispheres of the brain.

The circle of Willis is composed of the right and left internal carotid arteries joined by the
anterior communicating artery. The basilar artery (formed by the fusion of the vertebral
arteries) divides into left and right posterior cerebral arteries that are connected
(anastomsed) to the corresponding left or right internal carotid artery via the respective
left or right posterior communicating artery. A number of arteries that supply the brain
originates at the circle of Willis, including the anterior cerebral arteries that originate
from the anterior communicating artery.

In the embryo, the components of the circle of Willis develop from the embryonic dorsal
aortae and the embryonic intersegmental arteries.

The circle of Willis provides multiple paths for oxygenated blood to supply the brain if
any of the principal suppliers of oxygenated blood (i.e., the vertebral and internal carotid
arteries) are constricted by physical pressure, occluded by disease, or interrupted by
injury. This redundancy of blood supply is generally termed collateral circulation.

Arteries supply blood to specific areas of the brain. However, more than one arterial
branch may support a region. For example, the cerebellum is supplied by the anterior
inferior cerebellar artery, the superior cerebellar artery, and the posterior inferior
cerebellar arteries.

Venous return of deoxygenated blood from the brain

Veins of the cerebral circulatory system are valve-less and have very thin walls. The
veins pass through the subarachnoid space, through the arachnoid matter, the dura, and
ultimately pool to form the cranial venous sinus.

There are external cerebral veins and internal cerebral veins. As with arteries, specific
areas of the brain are drained by specific veins. For example, the cerebellum is drained of
deoxygenated blood by veins that ultimately form the great cerebral vein.

External cerebral veins include veins from the lateral surface of the cerebral hemispheres
that join to form the superficial middle cerebral vein.
 Etiology
Factor Rationale Present or Absent Justification
Gender Men are more Present Patient has lived in
common on having the Philippines for a
CVA because of the long period of time.
lifestyle, especially on
alcohol intake.
Heredity An individuals’ risk Present Mr. Eks’ Mother
may increase if a told us during
maternal or paternal interview that she
relative has had had a heart disease,
a stroke. Possible CAD, and she also
mechanisms include: said that Mr. Eks’
genetic heritability of father had stroke in
risk factors the past.
or susceptibility to
their effects; shared
environmental/lifestyle
factors;
interaction of genetic
and environmental
factors. Inherited
defects in the
clotting mechanism
can also increase risk.
Transcient Transient ischemic Present Mr. Eks had his
Ischemic Attack attacks (TIAs) are TIA on October 4,
(TIA) "warning strokes" that 2008
produce stroke-like
symptoms but no
lasting damage. TIAs
are strong predictors
of stroke. A person
who's had one or more
TIAs is almost 10
times more likely to
have a stroke than
someone of the same
age and sex who
hasn't.
Race African Americans Absent Patient is a Filipino,
have a much higher and has lived in the
risk of death from a Philippines his
stroke than Caucasians entire life so far.
do. This is partly
because blacks have
higher risks of high
blood pressure,
diabetes and obesity.
Precipitating Factors

Factor Rationale Present or Absent Justification

Alcohol Use The exact Present According to Mr.
pathogenic Eks’ wife he is a
mechanism is drinker. He drinks
unknown, but twice or thrice a
alcohol can week.
contribute to high
levels of
triglycerides,
produce cardiac
arrhythmias, and
cause
heart failure

Smoking Cigarette smoke Absent According to Mr.

contains carbon Eks’ wife he does
monoxide and not smoke.
nicotine as well as
numerous additional
toxic compounds.
Cigarette smoking
has a role in
promoting
the atherosclerotic
process particularly
in the carotid
arteries. (It is
thought that carbon
monoxide may play
a role in damaging
the arterial
endothelium).
Smoking also
causes
several changes in
the blood. They
include increased
adhesiveness and
clustering of
platelets,
shortened platelet
survival, faster
clotting time, and
increased viscosity
 of the blood, which
can
affect flow velocity.
Smokers have an
increased risk of
both ischemic and
hemorrhagic stroke.

Atrial Fibrilation Patients with atrial Present Upon gathering

fibrillation have a information from the
greatly increased chart, ECG shows
an Atrial Fibrillation
risk of embolic
strokes. Ineffective
contraction of the
atrium allows blood
to pool along its
walls and increases
thrombus formation.
Bits of these
thrombi can travel
through the left
ventricle, enter the
systemic circulation
and embolize the
brain.
Post open heart Strokes occurring in Present When Mr. EKs’ was
surgery this situation are 17 years old he had
usually the result of an open heart
surgically dislodged surgery at Philippine
plaques from the Heart Center.
aorta that travel
through the
bloodstream to the
arteries in the neck
and head, causing
stroke. Cardiac
surgery increases a
person's risk of
stroke by about 1
percent. Other types
of surgery can also
increase the risk of
stroke.
Heart Disease Any heart diseases Present According to
may produce mother, Mr. Eks
damage to the heart CHD that prompted
 wall or persistent Mr. Eks’ surgery
atrial fibrillation, and at present he has
both of which Rheumatic Heart
promote thrombus disease.
formation. Bits of
thrombus may break
off and embolize the
brain.

Diabetes Mellitus Diabetes increases Absent Mr. Eks’ wife and

the risk of ischemic his mother told us
strokes through that he does not
have diabetes
several interrelated
mellitus.
mechanisms that
favor (and
accelerate) the
formation of
atherosclerotic
plaque. In patients
with diabetes,
plaque is much
more common in the
smaller branches of
cerebral arteries
than in nondiabetics.
The narrowing of
these smaller
vessels can directly
increase
the risk of stroke.

High Cholesterol Concerning Absent Mr. Eks’ Laboratory

Level cerebrovascular showed he does nt
disease specifically, have high
what is known Cholesterol level.
is that elevated total
cholesterol and LDL
is associated with
increased degree
and progression
of carotid
atherosclerosis,
while elevated HDL
levels have the
opposite effect.
Hypertension Vessels that are Present According to
continuously Mother, after Mr.
subjected to high Eks’ surgery he
pressures are more experiences most of
likely to develop the time unstable BP
plaque, and it is or Hypertension.
more likely that the
endothelial surface
of the vessel will be
damaged, promoting
plaque rupture and
the formation of
thrombi. A
thrombus can
occlude the vessel
locally or can
break off and
embolize the brain.
 Symptomatology
Symptom Rationale Present or Absent Justification
Hemiparesis The resultant deficit Present During our duty, we
is believed to be due had observed
to the large weakness on his
representation of the right side of the
affected muscles in body.
the homunculus.
Aphasia Blood clot from the Present We have observed
CVA can prevent that Mr. Eks have
oxygen and slurred speech.
nutrients from
reaching nerve cells
thus, resulting to
cell death and the
affected body cease
to function.

Dysphagia Cranial nerves 9 and Present Mr. Eks has an NGT

10 are located at the for feeding purposes
left hemisphere of and upon gathering
the brain, which is data, his chart
the affected area, showed negative gag
and aids in the reflex.
eating process.

hemiplegia Due to damage of Present Upon performing

the lateral gaze Neurovital signs, his
center right side of the
body especially the
upper and lower
extremities cannot
move.
 DOCTOR’S ORDER

DATE DOCTOR'S ORDER RATIONALE REMARKS

April 20, Pls. admit to ICU under the The patient is in need of DONE
2009 service of Dr. E. Durban medical attention so he is
BP=150/100 admitted in Ricardo Limso
mmHg Hospital
CR=60bpm
RR= 18bpm
O2 sat= 100%
HGT=
5.2mmol/L
Dr. Durban is out of town, to see To facilitate continuous care DONE
patient, Dr. C.Fuentes
Consent to care -For legal purposes DONE
-to know if the patient agrees
on the terms of care of the
hospital
O2 inhalation at 4 LPM via breathing pattern is altered on DONE
nasal cannula patients having stroke
NPO The patient is maintained on DONE
NPO in order to prevent
aspiration and vomiting
Monitor VS every hour Vital signs serves as the DONE
baseline data of the patient's
entire stay in the hospital
Monitor I & O every hour urinary incontinence is DONE
common in stroke patients
Labs: These entire lab tests are DONE
1. CBC performed to screen for
2. Urinalysis alteration and to serve as a
3. ECG baseline data for future
4. FBS comparison.
5. Serum Creatinine
6. Serum Sodium, Potassium,
Calcium, Magnesium
7. Lipid Profile
8. SGPT
9. CXR- PA
10. HGT now
Start Venoclysis with DONE
D5W500cc at KVO rate − To facilitate in giving
IVTT medications
 Please insert NGT and Foley − For feeding purposes DONE
Catheter − to drain the patient’s
urinary bladder since he is
unable go to the comfort
room
Meds: DONE
1. Pantoprazole (Partoloc) 40mg All medications previously
IVTT now then 1 ampule O.D. ordered by attending
2. Citicoline ( Zynapse) 2 grams physician should be continued
IVTT now then 1 gram IVTT to hasten patient's recovery.
every 6 hours
3. Atorvastatin ( Lipitor) 80mg 2
tabs now/ NGT then 1 atb OD at
HS/ NGT
4. Lanoxin0.25mg 1 tab OD
Discontinue D5W500cc, shift to - For replacement of fluid DONE
PNSS 1L at 60cc/hour electrolytes balance
maintenance.
For cranial CT scan today CT scan provides detailed DONE
views of the body’s soft
tissues, including blood
vessels, muscle tissue, and
organs, such as the brain. It is
also used to determine any
mass or obstruction present in
the body
April 20, May accommodate to ROC For management and close DONE
2009 monitoring of patient’s
3:00 pm treatment.
ECG- AF
with MVR
Anterior wall
myo ischemia
Inc. RBBB
Awake but
aphasia
Motor: move
left
extremities
Grade 2/5
Left upper
extremities
1/5 left lower
extremities
Right
extremities=
0/5
Monitor VS and NVS every Vital Signs and Neuro Vital DONE
hour and record please. Signs serves as the baseline
data of the patient's entire stay
in the hospital
Insert NGT to facilitate the feeding
Start osteorized feeding at 50 ml for the patient to receive the
every 3 hours x 7 feedings, then needed nutrients he needs
flush with 25 ml water every because he is on NPO
after O.F.
Piracetam 1.2 grams IV x 30 All medications previously DONE
minutes. Now then 3 grams ordered by attending
every 6 hours physician should be continued
to hasten patient's recovery.
5:30 pm Refer for any unusualities Referral is done to correct DONE
CT scan unusualities as soon as
result: possible and to inform the
> non- attending physician of the
hemorrhagic patient's condition.
infarct with
slight mass
effect, left
fronto-
temporal
areas
extending to
the left basal
ganglia
11:40 pm Decrease Atorvastatin to 80mg Atorvastatin is given to DONE
½ tab OD HS decrease blood cholesterol.
The dosage is decreased since
the patient’s blood
cholesterol/LDL level has
already decreased.
Give pantoprazole P.O. 40 mg Pantoprazole is an anti- DONE
OD secretory drug.
April 21, Increase Osteorized Feeding to To meet the nutritional needs DONE
2009 100 ml every 3 hours then flush of the patient’s body.
4:55 am with 100cc water
1 PM Refer to Dra. Anuta for Neuro Referral is done to correct DONE
Evaluation unusualities as soon as
possible and to inform the
attending physician of the
patient's condition.
Rounds with Dr. C. Fuentes For monitoring and DONE
continuous care of the patient
 Start Mannitol 200ml IV for 30
Mannitol is a diuretic and at DONE
minutes now, then 160cc everythe same time decreases the
4 hours to run for 30 minutesblood pressure of the patient
IVF to follow with PLR 1L at For replacement of fluid DONE
60cc/ hour electrolytes balance
maintenance
Increase osteorized feeding to To meet the nutritional needs DONE
150ml every 3 hours then flush of the patient’s body.
with 150ml water
April 21, IVF to follow as PLR 1L at For replacement of fluid DONE
2009 80cc/ Hour electrolytes balance
4:30 pm maintenance.
April 22, Lactulose 40ml now then 30 ml Since the patient is unable to DONE
2009 OD HS defecate, lactulose is given to
aid in defecation.
April 22, Repeat urinalysis For further evaluation DONE
2009
2:30 pm
More Awake
but still
aphasia
(-) BM
Neurology: This is for the collaborative DONE
- Thank you very much for their health care of the patient.
referral Assessment of the patient is
- Impression: Large infarct, Left endorsed for the continuity of
MCAD care.
- Suggestion/ Comment
1. Curative manifestation
= may start to transfer on 5
days
2. Curative Citicoline IV
3. Suggest 2 D Echo if not yet
done
4. Suggest Rehab; referral
Suggest to instruct watchers to
To stimulate his neurologic DONE
keep on talking to patient function
IVF to follow with PLR 1L at For replacement of fluid DONE
80cc/hour electrolytes balance
maintenance.
April 22, Decrease Mannitol to 120 ml Mannitol is a diuretic and at DONE
2009 every 4 hours IV x 30 mins the same time decreases the
blood pressure of the patient
Increase O.F. to 200ml every 3 To meet the nutritional needs DONE
hours then flush with 200ml of the patient’s body.
water every after O.F.
April 22, Refer to Dra. Santos for P.T. For monitoring and DONE
2009 continuous care of the patient
4:40 pm
9 pm Repeat serum electrolytes( Na+, To evaluate the efficiency of DONE
K+) from AM, to include from serum electrolytes and to see
protime with INR if there are any complications.
April 23, Shift IV Piracetam to 1.2 g/ tab Piracetam is used to improve DONE
2009 1 tab BID memory process
6:15 am
Rehabilitation Medicine: For further evaluation and for DONE
- Thank you for your kind motor training.
referral
- seen and examine patient;
chart entries renewed
- will put him on a post stroke
rehab program
- kindly secure 3 PT sessions
IVF to follow PLR 1L at 80cc/ For replacement of fluid DONE
hour electrolytes balance
maintenance.
To follow PLR IV at 80cc/ hour For replacement of fluid DONE
electrolytes balance
maintenance.
Decrease Mannitol drugs to Mannitol is a diuretic and at DONE
100ml every 4 hours x 30 the same time decreases the
minutes blood pressure of the patient
April 23, IVF to follow as PLR 1L at For replacement of fluid DONE
2009 80cc/hr electrolytes balance
maintenance.
April 23, Increase O.F. to 250ml then To meet the nutritional needs
DONE
2009 flush with water 200ml every of the patient’s body.
2:20pm after O.F.
I’ll be out of town today until To inform and be aware the DONE
April 26, 2009 medical services done with
the patient.
April 24, Please inform Dr. Santos To have further evaluation. DONE
2009
10:30 am
Decrease citicoline to 1 gram Improvement of speech was DONE
every 8hrs. IV noted so Citicoline was
decreased.
Rehabilitation Medicine: For further evaluation and for DONE
-latest serum electrolytes noted motor training.
- for initiation of rehab session
still
PLR at 80cc/hr For replacement of fluid DONE
 electrolytes balance
maintenance.
Rehabilitation medicine For further evaluation and for DONE
nd
-tolerated 2 session of rehab motor training.
family well with stable VS and
NVS today
- will continue rehab program
on Monday
PLR 1L at 80cc/hr For replacement of fluid DONE
electrolytes balance
maintenance.
April 24, Replace foley catheter and Indwelling catheters should be DONE
2009 urobag replaced every 3 days since
(+) on- follow there is always that risk for
(+) active infection.
movement
Left UE/LE
(-) Homan’s
sign
Still unable to
protrude
fingers
For urinalysis (please use For further evaluation DONE
aseptic technique)
April 25, Alprazolam 250mg 1 tab/ NGT For short term relief of DONE
2009 anxiety
Mupirocin (Bactroban) TID to For treatment of blisters DONE
affected areas
April 26, Sultamicillin ( Unasyn) 750mg For treatment of infections DONE
2009 tab, 1 tab, PO
4:15 pm Turn to sides every 2 hours To prevent bed sores DONE
Alprazolam 250mg tab; 1 tab For short term relief of DONE
every 12 hours PRN for anxiety
persistent hiccups
April 26, For 2D echo To examine the working heart DONE
2009 and to display moving images
9:45 pm of its action.
Decrease Mannitol 60cc every 4 Mannitol is a diuretic and at DONE
hours the same time decreases the
blood pressure of the patient

Endorsing patient back to rehab For monitoring and DONE

continuous care of the patient
Start Imdur 60 mg tab; ½ tab at For acute angina attacks DONE
HS
Review of meds: All medications previously DONE
 1. Citicoline tab 500mg 2 tabs ordered by attending
every 12 hours physician should be continued
2. Imdur 60 mg ½ tab at HS to hasten patient's recovery.
3. Mannitol 60cc every 4 hours
4. Lactulose 30cc at HS
5. Piracetam 1.2gms., 1 tab
BID
6. Alprazolam 250mg 1 tab
every 12 hours PRN for Hiccups
7. Lanoxin 1 tab OD
8. Pantoprazole 40mg 1 tab
OD at HS
10. Unasyn 750mg 1 tab BID
11. Bactroban apply TID to
affected areas
April 27, Start bladder training, clamp In preparation for the removal DONE
2009 catheter release for 30 minutes of foley catheter.
1:30 pm every 4 hours
Rehabilitation Medicine: PT sessions enhance motor DONE
>Kindly secure another 3 PT skills to have a faster
session please recovery. Oral hygiene is to
> For oral hygiene with bactidol prevent further infection from
BID please and also provide the respiratory tract.
watcher with OS covered/ Paracetamol relieves fever.
padded tongue depressor
> Paracetamol 500mg 1 tab now
then every 4 hours for fever
#13 IVF with PLR 1L to run at For replacement of fluid DONE
80cc/hr electrolytes balance
maintenance.
Vandol ointment, apply TID to To treat diaper rash DONE
diaper rash, after cleaning area
April 27, Rehabilitation medicine: For further evaluation and for DONE
2009 - cardiac findings (2D ECHO) motor training.
5:20 pm noted- cardiac precautions
Still unable to observed during rehabilitations
protrude - kindly secure 2 OT sessions
fingers for pre- finding and pre- speech
training
SALAMAT PO
April 28, IVF to follow PLR 1L at For replacement of fluid DONE
2009 80cc/hr electrolytes balance
1:30 pm maintenance.
Remove urinary catheter Condom catheter is inserted DONE
change to condom catheter since patient is now able to
void freely.
 Discontinue Lactulose Drug is discontinued since DONE
temporarily patient is now able to
defecate.
Nebulize with Ambroxol/ A bronchodilator and DONE
Bisolvon + NSS TID mucolytic which aids in the
removal of phlegm.
April 29, Chest tapping after each For faster removal of DONE
2009 nebulization secretions/phlegm.
7:50 am
10:30 am May give gelatine cubes PRN To exercise the patient’s DONE
per orem, Watch out for mastication process
aspiration
Repeat CBC today For further evaluation. DONE
Nebulize with ambroxol for To aid in the removal of DONE
inhalation 10gtts + PNSS 2ml phlegm
TID
Rehabilitation medicine: To work-out the patient’s DONE
-for continuation of PT and OT motor and verbalization skills.
sessions today
May have sips of gelatine with To prevent from aspiration. DONE
SAP
7:01 pm Consume and discontinue IVF All meds were ordered orally. DONE
Febrile No more IVTT meds.
Increase
WBC 11.06
For WBC 9
April 30, Remove NGT after 6 am To prevent Mr. Eks’ to DONE
2009 feeding tomorrow become independent from
using NGT when eating.
April 30, May have general liquids Since Mr. Eks’ NGT will be DONE
2009 ( including O.F) to very soft diet removed, general liquids was
3:20pm thereafter STRICT ordered to slowly introduce
ASPIRATION PRECAUTION foods into the body through
the mouth.

DIAGNOSTIC EXAM
 ECHOCARDIOGRAPHY AND COLOR FLOW DOPPLER
Date: April 27, 2009
QUANTITATIVE
Dimension Patient Normal Function Patient Normal
LV (ed) 5.4 4.5-5 LVEDV 140.1
LV (es) 2.9 LVESV 33.3
RV (ed) 3.6 2.2-4 STROKE 106.8
VOL
LA (es) 4.5 3-3.5 CO 7.3
RA (es) 4.2 3.5-4.5 CI
AORTA 3.4 3.5 EF % 76 55-77
PA 3.2 3-4 FS % 45 2.2-4
IVS (ed) 1.4 .8-1.1 VCF .8-1.5
(CIR)/SE
IVS (es) 1.8 EPSS 0.9 <=1
LVPW (ed) 1.25 0.8-1.1 WALL < 195
STRESS
LVPW (es) 1.8 WALL < 600
STRESS
MV ANNU 4.7 LV WMSI 1.0
TV ANNU 3.9 HEART 69
RATE
LVET RHYTHM AF

SPECTRAL AND COLOR FLOW DOPPLER

VALVE MX VEL (m/s) PEAK GRAD mmHg
Aortic 1.4 2.0 7.5 17.0
Mitral 2.3 20.6
Tricuspid 0.5 1.2
Pulmonic 0.8 2.8
Pat = 122

INTERPRETATION:

Rheumatic Heart Disease, several mitral stenosis with mitral valve area of 0.8 cm²
by pressure half time and 0.9 cm² by planimetry, peak gradient of 20.6 mmHg. The
anterior mitral valve leaflet is thickened with calcifications at the margins. The posterior
mitral valve leaflet is fixed. There is restriction of motion of both leaflets with anterior
doming motion of the anterior mitral valve leaflet during diastole. Both commissures are
fused. The subvalvar apparatus is thickened. Wilkin’s score of 8 (subvalvar apparatus – 2,
mobility – 2, calcifications – 2, thickening - 2).
Structurally, normal tricuspid, aortic and pulmonic valves with good opening and
closing motion.
 Dilated left ventricle with concentrically hypertrophied walls. There is adequate
wall motion and contractility.
Slightly dilated right ventricle with adequate wall motion and contractility.
Dilated right and left arterial sizes without evidence of thrombus
Normal aortic root.
Normal main pulmonary artery and pulmonary artery systolic pressure.
No pericardial effusion.

DOPPLER STUDY:

Mild mitral, tricuspid and aortic regurgitations.

Trivial pulmonic regurgitation.

CONCLUSION:

Rheumatic Heart Disease, severe mitral stenosis with mitral valve area of 0.9 cm²,
peak gradient of 20.6 mmHg. Wilkin’s score of 8.
Eccentric left ventricular hypertrophy with preserved overall resting systolic
function.
Dilated right ventricle with adequate wall motion and contractility.
Dilated left and right arterial sizes without evidence of thrombus.
Mild mitral, tricuspid, and aortic regurgitations.
Trivial pulmonic regurgitation.

RADIOLOGY
Clinical Impression: Body Malaise
Part examined: Chest

FINDINGS:

There is no definite radiographic evidence of active pulmonary infiltrate. Vascular

shadows however appear engorged. Cardiac shadow appears enlarged with laterally
displaced apex and convex left atrial border. Sternotomy wires are appreciated.
Diaphragm and costophrenic sulci are intact. No other significant findings.

IMPRESSION:

Cardiomegaly is considered left sided predominance with pulmonary congestion.

CRANIAL CT SCAN

FINDINGS:

Multiple plain axial tomographic sections of the head were obtained.

Low attenuation density changes are noted in the left fronto-temporal areas
extending into the left basal ganglia.
No external axial fluid collection noted.
The frontal horn of the left lateral ventricle is compressed with slight midline shift
to the right.
The rest of the ventricles are unremarkable.
The sulci and cisterns are slightly compressed on the affected side.
The posterior fossa, sella, orbits, paranasal sinuses, and petromastoids are
unremarkable.

IMPRESSION:

Non hemorrhagic infarct with slight mass effect, left frontotemporal areas
extending into the left basal ganglia.

HEMATOLOGY
Date: April 29, 2009

Parameter Results Units Lower Upper limits

limits
Hemoglobin 153 g/L 135 180

- To identify the amount of oxygen

carrying protein contained within the
RBC.

Hematocrit 0.45 0.40 0.54

-to identify the percentage of the blood

volume occupied by red blood cells.
-decreased HCT indicates blood loss,
anemia, blood replacement therapy,
and fluid balance, and screens red
blood cells status

RBC 4.86 10ˆ 5.5 6.5

12/L
-to know the amount of RBC in the
blood.
-a decreased count may indicate
anemia, fluid overload, or severe
bleeding

WBC 11.60 10 ˆ 5 10
9/L
-to determine infection or
inflammation in the body and monitor
its responses to specific therapies.
-a leukocyte count is elevated in
infectious diseases of the heart (e.g.,
acute bacterial endocarditis)
-increases because large number of
white cells are necessary to dispose of
the necrotic tissue resulting from the
infarction.

Neutrophil 0.80 0.55 0.65

-active phagocytes; number increases

rapidly during short-term or acute
infections.
- increases in localized tissue death
(ischemia) due to heart attack, burns,
carcinoma.
Lymphocyte 0.09 0.25 0.35

-part of immune system; one group (B

lymphocytes) produces antibodies;
other group (T lymphocytes) involved
in graft rejection, fighting tumors and
viruses, and activating B lymphocytes
- decreased by severe debilitating
illness such as heart failure, renal
failure, and advanced TB
Monocyte 0.09 0.03 0.06

-active phagocytes that become

macrophages in the tissues; long-term
“clean-up team”
-an increase may respond to
corticosteroid, with pus conditions,
hemorrhage.
Eosinophil 0.02 0.02 0.04

-kills parasitic worms; might

pathocyte antigen-antibody complexes
and inactive inflammatory chemicals.
Basophil 0.00 0 0.01

- granules contain histamine

(vasodilator chemical), which is
discharged at sites of inflammation

Platelet count 129 150 350

-is the number of platelets in a given

volume of blood.
-responsible for beginning the process
of coagulation, or forming a clot,
whenever a blood vessel is broken
-both increase and decrease can point
to abnormal conditions of excess
bleeding or clotting.

Date: April 20, 2009

 Parameter Results Units Lower Upper limits
limits
Hemoglobin 164 g/L 135 180
Hematocrit 0.47 0.40 0.54
RBC 5.20 10ˆ 12/L 5.5 6.5
WBC 9.27 10 ˆ 9/L 5 10
Neutrophil 0.68 0.55 0.65
Lymphocyte 0.18 0.25 0.35
Monocyte 0.10 0.03 0.06
Eosinophil 0.04 0.02 0.04
Basophil 0.00 0 0.01
Platelet count 148 150 350

PROTIME

Date: April 24, 2009

Result:
Control: 13,1 s
Pts. Value: 13, 3 s
INR: 1, 16 s
Ref. range: 0.87-1.11
2-2.5 = prophylaxis if deep vein thrombosis including high
risk surgery
2-3 = hip surgery and operation for fractured femur
2-3 = treatment of deep vein thrombosis, pulmonary
embolism and transcient ischemic attack
2-4 = recurrent deep vein thrombosis, pulmonary embolism,
arterial disease including myocardial infarction, arterial
grafts, cardiac prosthetic valves and grafts.

URINALYSIS
Date: April 26, 2009

Macroscopic
Physical: Chemical:
Color: bloody specific Gravity: 1.030 Albumin: ++++ (4 plus)
Appearance: cloudy Reaction (pH): acidic Sugar: negative
(5.0)
Microscopic
Cells:
Pus cells: NUM/Hpf
Erythrocytes/RBC: NUM/Hpf

Date: April 22, 2009 @ 3:58 pm

Macroscopic
Physical: Chemical:
Color: yellow specific Gravity: 1.010 Albumin: trace
Appearance: slightly Reaction (pH): acidic Sugar: negative
cloudy (6.0)
Microscopic
Cells:
Pus cells: 1-5/Hpf
Erythrocytes/RBC: 15-30/Hpf

Date: April 22, 2009 @ 11:59 am

Macroscopic
Physical: Chemical:
Color: yellow specific Gravity: 1.010 Albumin: trace
Appearance: slightly Reaction (pH): 6 Sugar: negative
cloudy
Microscopic
Cells:
Pus cells: 1-5/Hpf
Erythrocytes/RBC: 15-30/Hpf
Squamous: ++ (2 plus)
Bacteria: few
Mucus threads: few
CLINICAL CHEMISTRY
Date: April 24, 2009 @ 11: 59 am

Test Result Ref. range SI units

Soduim, substc 135. 2 135-148 mmol/L
Potassium, substc 3,69 3,5-5,3 mmol/L

Date: April 21, 2009 @ 11:08 am

Test Result Ref. range SI units

Glucose, substc 4.88 3, 89-5, 83 mmol/L
SGPT, Activity C. 56, 11 M: 0-41 u/L
Cholesterol 3, 52 Up to 5,2 mmol/L
ADL 0, 77 More than 0, 91 mmol/L
LDL 2, 41 Less than 3,5 mmol/L
Urate, substc 0, 27 M: 0, 21 – 0, 42 mmol/L
Triglycerides 0, 75 Up to 1,7 mmol/L

Date: April 20, 2009 @ 9:15 pm

Test Result Ref. range

K+, substc 3.62 3,5-5,3
Ca+, substc 1.15 1,13-1,32
SGPT, activity C 56.00 M: 0-41
Crea, substc 66, 21 M: <50 y.o.: less than
115
>50 y.o.: less than 124
Na+, substc 146 135-148
Mg 0, 30 0,7 – 0, 98
 Generic Name: Digoxin
Brand Name: Lanoxin

Classification Dose Mode of action Indication Contraindications Drug Side effects Nursing
interactions responsibilities
Pharmacologic: 1 tab, Inhibits sodium- Heart failure, 1. Contraindicated Amiloride: may CNS: 1.Before giving

cardiac O.D., potassium-activated paroxysmal in patients decrease digoxin agitation, drug, take apical-

glycoside 0.25 adenosine supraventricular hypersensitive to effect and fatigue, radial pulse for 1

mg triphosphatase, tachycardia, drug and in those increase digoxin generalized minute. Record

Inotropics promoting movement atrial with digitalis- excretion. muscle and notify

of calcium from fibrillation and induced toxicity, Amiodarone, weakness, physician of any

extracellular to flutter ventricular diltiazem, hallucinations, changes (sudden

intracellular fibrillation, or indomethacin, dizziness, increase or

cytoplasm and ventricular nifedipine, headache, decrease in pulse

strengthening tachycardia unless quinidine, stupor, rate, pulse deficit,

myocardial caused by heart verapamil: may vertigo. irregular beats, and

contraction. Also acts failure. increase digoxin CV: regularization of a

on CNS to enhance 2. Use with level. arrhythmias, previously

vagal tone, slowing extreme caution in Amphotericin B, heart block. irregular rhythm).

conduction through patients with acute carbenicilin, EENT: 2.Toxic effects on

the SA and AV nodes MI, incomplete corticosteroids, blurred vision, the heart may be

AV block, sinus diuretics, diplopia, light life-threatening

bradycardia, ticarcillin: may flashes, and require

PVCs, chronic cause photophobia, immediate

constrictive hypokalemia, yellow-green attention.

pericarditis, predisposing halos around 3.Monitor digoxin

hypertrophic client to toxicity. visual images. and potassium

cardiomyopathy, Antacids: may GI: anorexia, level.

renal insufficiency, decrease nausea, 4.Teach

severe pulmonary absorption of oral diarrhea, responsible family

disease, or digoxin. vomiting. member about

hypothyroidism. Antibiotics, drug action,

propafenone, dosage regimen,

ritonavir: may how to take pulse,

increase risk of reportable signs,

toxicity. and follow-up

Anticholinergics: care.

may increase 5.Inform to report

absorption of pulse less than 60

digoxin tablets. beats/minute or

Beta-blockers, more than 110

calcium-channel beats per minute,

blockers: may or skipped beats or

have additive other rhythm

effects on AV changes.

node conduction 6. Instruct to report

causing advanced adverse reaction

or complete heart immediately.

block.

Cholestyramine,

colestipol,

metoclopramide:
 may decrease

absorption of oral

digoxin. Give

digoxin 1 ½

hours before or 2

hours after other

drugs.

Parenteral

calcium,

thiazides: may

cause

hypercalcemia

and

hypomagnesemia.

Generic Name: Levofloxacin

Brand Name: Levaquin
 Classification Dose Mode of Indication Contraindications Drug Side effects Nursing
action interactions responsibilities
Pharmacologic 1 tab, Inhibits - mild to 1.Contraindicated Antidiabetics: CNS: 1.Administer drug as

class.: O.D., bacterial DNA moderate skin in patients may alter encephalopathy, prescribed even if

fluoroquinolone 500 gyrase and and skin hypersensitive to glucose level. seizures, dizziness, signs and symptoms

mg prevents DNA structure drug, its Iron salts: may headache, disappear.

replication, infections components, or decrease insomnia, pain, 2.Advise to take drug

transcription, other absorption of paresthesia. with plenty of fluids.

repair, and fluoroquinolones. levofloxacin, CV: chest pain, 3.Instruct to avoid

recombination 2.Use cautiously in reducing anti- palpitations, activities that require

in susceptible patients with infective vasodilation. alertness.

bacteria. history of seizure response. GI: 4.Instruct to stop drug

disorders or other NSAIDS: may pseudomembranous and notify prescriber if

CNS disorders. increase CNS colitis, abdominal rash or other signs and

stimulation. pain, constipation, symptoms of

Monitor for diarrhea, dyspepsia, hypersensitivity

seizure activity. flatulence, nausea develop.

Warfarin and and vomiting. 5.Inform that drug

derivates: may Hematologic: may cause abnormal

increase effect lymphopenia, ECG.

of oral eosinophilia,

anticoagulant. hemolytic anemia.

Monitor PT and Metabolic:

INR. hypoglycemia.

Musculoskeletal:

back pain, tendon

rupture.

Respiratory:

allergic

pneumonitis

Skin: erythema

multiforme,

photosensitivity,
 pruritus, rash.

Other: anaphylaxis,

multisystem organ

failure,

hypersensitivity

reactions.

Generic Name: Citicoline

Brand Name: Cholinerv

Classification Dosag Mode of Action Indication/s Contraindicatio Drug-drug Adverse Nsg.

e n Interaction Reaction Responsibilties
Neuroprotective 500mg - Citicoline is an CVD in acute Parasympatheti Somazine Gastrointestina •Somazine
; CNS Drugs & 2 tabs interneuronal & recovery c hypertonia potentiates the l disorders. must not be
Agents for communication phase, effects of L- Allergic administered
ADHD enhancer. It symptoms & dopa. reaction: along with
increases the signs of Incompatibilities Itching or medicaments
neurotransmissio cerebral : Somazine must hives, swelling containing
n levels because insufficiency not be in your face or meclophenoxat
it favors the (dizziness, administered hands, e
synthesis and memory loss, with products swelling or
production speed poor containing tingling in
of dopamine in concentration meclofenoxate your mouth or
the striatum, , (clophenoxate) throat, chest
acting then as a disorientation tightness,
dopaminergic , recent trouble
agonist thru the cranial breathing, or
inhibition of trauma & rash, Low
tyrosine- their blood pressure
hydroxylase. sequelae.) (faintness,
dizziness),
Slow or fast
heart beat,
Headache,
Nausea,
vomiting, or
diarrhea (loose
BMs)

Generic Name: Alprazolam

Brand Name: Niravam, Xanax
Classification Dosage Mode of Action Indication/s Contraindication Drug-drug Adverse Nsg.
Interaction Reaction Responsibilties
250mg 1 Exact Management -Contraindicated - Increased - CNS: Take this drug
tab every mechanisms of of anxiety with CNS depression Transient, exactly as
12 hours action not disorders, hypersensitivity with alcohol, mild prescribed;
PRN understood; short-term to other CNS drowsiness take extended-
main sites of relief of benzodiazepines, depressants, initially; release form
action may be symptoms of psychoses, acute propoxyphene sedation, once daily in
the limbic anxiety; narrow-angle - Increased depression, the AM.
system and anxiety glaucoma, effect with lethargy, •
reticular associated shock, coma, cimetidine, apathy, Do not drink
formation; with acute alcoholic disulfiram, fatigue, light- grapefruit juice
increases the depression. intoxication with omeprazole, headedness, while on this
effects of - Treatment depression of isoniazid, disorientation, drug.
gamma- of panic vital signs, hormonal anger, •
aminobutyrate, attacks with pregnancy contraceptives, hostility, Do not stop
an inhibitory or without (crosses the valproic acid episodes of taking drug
neurotransmitter; agoraphobia. placenta; risk of - Decreased mania and (long-term
anxiety blocking - Unlabeled congenital effect with hypomania, therapy)
effects occur at uses: Social malformations, carbamazepine, restlessness, without
doses well below phobia, neonatal rifampin, confusion, consulting
those necessary premenstrual withdrawal theophylline crying, health care
to cause syndrome, syndrome), labor - Possible delirium, provider.
sedation, ataxia. depression and delivery increased risk headache, •
("floppy infant" of digitalis slurred Avoid alcohol,
syndrome), toxicity with speech, sleep-inducing,
lactation digoxin dysarthria, or over-the-
(secreted in - Decreased stupor, counter drugs.
breast milk; antiparkinson rigidity, •
infants become effectiveness of tremor, These side
lethargic and levodopa with dystonia, effects may
lose weight). benzodiazepines vertigo, occur:
- Use cautiously Contraindicated euphoria, Drowsiness,
with impaired with nervousness, dizziness (less
liver or kidney ketoconazole, difficulty in pronounced
function, itraconazole; concentration, after a few
debilitation. serious toxicity vivid dreams, days, avoid
can occur psychomotor driving a car or
retardation, engaging in
extrapyramidal other
symptoms; dangerous
mild activities if
paradoxical these occur);
excitatory GI upset (take
reactions drug with
during first 2 food); fatigue;
weeks of depression;
treatment dreams;
-CV: crying;
Bradycardia, nervousness.
tachycardia, •
cardiovascular Report severe
collapse, dizziness,
hypertension, weakness,
hypotension, drowsiness that
palpitations, persists, rash
edema or skin lesions,
- difficulty
Dermatologic: voiding,
Urticaria, palpitations,
pruritus, rash, swelling in the
dermatitis extremities.
-EENT:
Visual and
auditory
disturbances,
 diplopia,
nystagmus,
depressed
hearing, nasal
congestion
-GI:
Constipation,
diarrhea, dry
mouth,
salivation,
nausea,
anorexia,
vomiting,
difficulty in
swallowing,
gastric
disorders,
hepatic
dysfunction

Generic Name: Pantoprazole

Brand Name: Protonix

Classification Dosage Mode of Indication/s Contraindication Drug-drug Adverse Nsg.

Action Interaction Reaction Responsibilties
Antisecretory 40 mg 1 Gastric acid- Oral: Short- Contraindicated Decreased CNS: -Instruct
agent; Proton tab OD pump term (< with absorption of Headache, patient to take
pump inhibitor: 8 wk) and hypersensitivity ketoconazole and dizziness, medication as
inhibitor Suppresses long-term to any proton itraconazole; may asthenia, directed for the
gastric acid treatment of pump inhibitor slightly increase vertigo, full course of
secretion by GERD or any drug digoxin plasma insomnia, therapy, even
specific (gastric components. concentration; may apathy, if feeling
inhibition of esophageal • reduce plasma anxiety, better.
the reflux disease) Use cautiously concentration of paresthesias, -Advise patient
hydrogen- • with pregnancy, atazanavir, avoid dream to avoid
potassium IV: Short-term lactation concomitant use; abnormalities alcohol,
ATPase (7–10 days) may enhance • products
enzyme treatment of anticoagulant Dermatologic: containing
system at GERD in effect of Rash, aspirin or
the secretory patients coumarins; may inflammation, NSAIDs, and
surface of unable to cause gastric urticaria, foods that may
the gastric continue oral mucosal irritation pruritus, cause an
parietal therapy with alcohol; may alopecia, dry increase in GI
cells; blocks • increase levels or skin irritation,
the final step Treatment of effects of: • -Advise patient
of acid pathological bosentan, dapsone, GI: to report onset
production. hypersecretory fluoxetine, Diarrhea, of black, tarry
conditions glimepiride, abdominal stools;
associated glipizide, losartan, pain, nausea, diarrhea; or
with montelukast, vomiting, abdominal pain
Zollinger- nateglinide, constipation, to health care
Ellison paclitaxel, dry mouth, professional
syndrome and phenytoin, tongue promptly.
other warfarin, and atrophy -Administer
neoplastic zafirlukast; may • once or twice a
conditions decrease levels or Respiratory: day. Caution
• effects of: URI patient to
Unlabeled aminoglutethimide, symptoms, swallow tablets
uses: carbamazepine, cough, whole; not to
Treatment of phenytoin, and epistaxis cut, chew, or
peptic ulcer rifampicin. • crush them.
Other: -Arrange for
Cancer in further
preclinical evaluation of
studies, back patient after 4
pain, fever wk of therapy
for
gastroreflux
disorders.
Symptomatic
improvement
does not rule
out gastric
cancer; gastric
cancer did
occur in
preclinical
studies.
-Maintain
supportive
treatment as
appropriate for
underlying
problem.
-Switch
patients on IV
therapy to oral
dosage as soon
as possible.
-Provide
additional
comfort
measures to
alleviate
discomfort
from GI effects
and headache.
Generic Name: Chlorpromazine
Brand Name: Largactil

Classificatio Dosag Mode of Indication/s Contraindicati Drug-drug Interaction Adverse Nsg.

n e Action on Reaction Responsibiltie
s
Antipsychoti 100m Chlorpromazi Psychotic Cross- ↑Effects These include Take drug
c g¼ ne is an disorders, sensitivity w/ W/amodiaquine,chloroqui sedation, dry exactly as
tab aliphatic N/V*, phe- ne, sulfadoxine– mouth, ordered.
every phenothiazine. apprehensio nothiazines; pyrimethamine, constipation •
6 Phenothiazine n, in- NAG antidepressants, narcotic , urinary Meds take 6
hours s are thought tractable analgesics,propranolol, retention, wks or longer
to elicit their hiccups quinidine, BBs, MAOIs, possible to achieve full
antipsychotic TCAs, EtOH, kava kava; lowering of clinical effect.
and antiemetic ↑effects OFanti- seizure •
effects via cholinergics, centrally threshold, WBC
interference acting antihypertensives, uncontrollable monitored for
with central propranolol, valproic acid; movements of 3 months.
dopaminergic ↓ef-fectsW/antacids, the tongue, (WOF signs
pathways in antidiarrheals, face, lips, of infection)
the barbiturates, Li, tobacco; arms, or legs, •
mesolimbic ↓effects muscle Avoid driving
and medullary OFanticonvulsants, spasms of the & operating
chemoreceptor guanethidine, levodopa, face or neck, machineries.
trigger zone Li, warfarin. and severe •
areas of the restlessness or Avoid direct
brain, tremor. sunlight.
respectively. Appetite may •
be increased Avoid
with resultant extremes in
weight gain, temperatures
Glucose & increased
tolerance exercise.
 may be •
impaired. Change
positions
Photosensitivit slowly.
y may occur, •
resulting in Alipathic
increased risk phenothiazine
of sunburn. s

pink-red
brown urine.
•
Suggest
lozenges,
hard candy
for dry
mouth.
•
Changes to
sexual
functioning &
menstruation.
Generic Name: Paracetamol
Brand Name: Aeknil

Classification Dosage Mode of Action Indication/s Contraindication Drug-drug Adverse Nsg.

Interaction Reaction Responsibilties
Anti-pyretic; 500mg, Paracetamol Mild pain; Contraindicated Anticoagulant When taken •
analgesic 1 tab reduces fever and Fever in patients drugs (warfarin) at the Use liquid form
PRN relieves the hypersensitive - dosage may recommended for children and
muscular pain to drug. require dose, side- patients who
characteristic of -Use cautiously reduction if effects of have difficulty
influenza. This is a in patients with paracetamol and paracetamol swallowing.
nontoxic drug that long term anticoagulants are rare. Skin •
has excellent alcohol use are taken for a rashes, blood In children,
gastric tolerance because prolonged disorders and don’t exceed
and is increasingly therapeutic period of time a swollen five doses in 24
accepted and doses cause • pancreas have hours.
used.Phenylephrine hepatotoxicity Paracetamol occasionally •
reduces in these patients. absorption is happened in Advise patient
congestion, edema -Hematologic: increased by people taking that drug is
and secretions that hemolytic substances that the drug on a only for short
cause nasal anemia, increase gastric regular basis term use and to
obstruction, and neutropenia, emptying, e.g. for a long consult the
provides a leucopenia, metoclopramide time. One physician if
bronchodilatory pancytopenia. • advantage of giving to
effect without -Hepatic: Paracetamol paracetamol children for
increasing cardiac Jaundice absorption is over aspirin longer than 5
rate. -Metabolic: decreased by and similar days or adults
Carbetapentane Hypoglycemia substances that drugs (eg for longer than
fights against -Skin: rash, decrease gastric ibuprofen and 10 days.
cough, and urticaria. emptying, e.g. diclofenac) is •
vitamins B1 and C propantheline, that it won't Advise patient
aid in antidepressants upset your or caregiver
strengthening with stomach or that many over
organic defense anticholinergic cause it to the counter
mechanisms. properties, and bleed.A products
narcotic paracetamol contain
analgesics overdose is acetaminophen;
• particularly be aware of this
Paracetamol dangerous when
may increase because the calculating total
chloramphenicol liver damage dailydose.
concentrations may not be •
• obvious for Warn patient
The risk of four to six that high doses
paracetamol days after the or unsupervised
toxicity may be drug has been long term use
increased in taken. Even if can cause liver
patients someone who damage.
receiving other has taken a
potentially paracetamol
hepatotoxic overdose
drugs or drugs seems fine
that induce liver and doesn't
microsomal have any
enzymes such as symptoms,
alcohol and it's essential
anticonvulsant that they are
agents taken to
• hospital
Paracetamol urgently. An
excretion may overdose of
be affected and paracetamol
plasma can be fatal.
concentrations
altered when
given with
probenecid
•
Colestyramine
reduces the
absorption of
paracetamol if
given within 1
hour of
paracetamol.
Generic Name: Isosorbide mononitrate
Brand Name: Imdur
Classification Suggested Mode of Indication Contraindication Drug Adverse Effects Nursing Responsibilities
Dose Action Interactions
Nitrates 60 mg tab; -Thought to Acute Anginal - Contraindicated - CNS: headache, - Monitor blood
½ tab at reduce Attacks: to prevent in patients with Antihypertensiv dizziness, pressure and
HS cardiac situations that amy hypersensitivity e: may increase weakness intensity and
oxygen cause angina or idiosyncrasy to hypotensive duration of drug
demand by attacks nitrates and in effects CV: orthostatic response
decreasing those with severe Hypotension, - Drug may cause
preload and hypotension, tachycardia, headache,
afterload. angle- closure palpitations, especially at the
- Drugs may glaucoma, ankle edema, beginning of the
also icreased ICP, flushing, therapy. Dosage
increase shock, or acute fainting may be reduced
blood flow MI with low left temporarily, but
through the ventricular filling EENT: burning tolerance usually
coronary pressure. develops. Treat
vessels. - use cautiously in GI: nausea and headache with
patients with vomiting Aspirin or
blood volume Acetaminophen
depletion or mild Skin: cutaneous - Caution patient
hypertension vasodilation, to take drug
rash regularly as
prescribed, and
to keep it
accessible at all
times.
- Advise patient
that stopping
drug abruptly
may cause spasm
of the coronary
arteries with
increased abgina
symptoms and
potential risk of
heart attack.
- Caution patient
to avoid alcohol
because it may
worsen low
blood pressure
effects.
- Warn patient not
to confuse S.L.
Brand Name: Vandol ointment
Classification Suggested Mode of Indication Contraindication Drug Adverse Effects Nursing Responsibilities
Dose Action Interactions
Emollient TID on Used to Soothes pain and Preparations The topical Most emollients - Frequent application is
affected rehydrate helps healing of containing application of can be used usually needed and
areas and thus minor wounds and corticosteroids zinc- or safely and continued prophylactic
soothe the burns, protects skin are generally calamine- effectively with use is usually
skin. Their from diaper rash. contraindicated containing no side effects. recommended even after
use is emollients may However, if initial improvement
valuable in further promote redness, occurs.
all healing. irritation or
conditions itching occur or - Excessive drying and
characterize continue, notify defatting of the skin
d by your doctor or should be avoided, e.g.
dryness, pharmacist. hot baths, alcoholic skin
scaling and Inform your preparations, detergents,
cracking of doctor if the alkaline soaps, etc.
the skin. condition for
which this - Urea and other
medication was moisturising agents
prescribed does (humectants) are
not improve incorporated into several
after a few emollient creams and
days. If you lotions. Such
notice other preparations may be
effects not useful in the dry and
listed above, scaly eczemas as well as
contact your in psoriasis.
doctor or
pharmacist. - Camphor, menthol and
phenol are mildly
antipruritic additives of
certain emollients.

- Some ingredients may

cause hypersensitivity
reactions - most notably
lanolin, certain
preservatives, fragrances
and antibacterials.
Generic Name: Sultamicillin
Brand Name: Unasyn

Side Effects/
Classificat Suggested Mode of Contra- Drug Adverse Nursing
ions Dose Actions Indications indications Interactions Reactions Responsibilities
Antibiotic 750mg Sulbactam History of -Allergic
Upper & Drug-drug. 1. Instruct patient
tab; 1 tab, blocks the allergic reaction reaction,
lower resp -Allopurinol: The on proper use of the
PO enzyme to any concurrent anaphylactoid drug
tract
administration of
which penicillins. reaction and
infections eg allopurinol and 2. Urge patient to
breaks down sinusitis, ampicillin anaphylactic
increases avoid cigarette
ampicillin shock.
otitis media, substantially the smoking because
and thereby tonsillitis, incidence of -Dizziness
rashes in patients this may increase
aallows -
bacterial receiving both gastric acid
ampicillin to pneumonias, drugs as diarrhea/loose
compared to secretion and
attack and bronchitis, stools, nausea,
patients receiving worsen disease
kill the ampicillin alone. Epigastric
UTI,
bacteria. distress, 3. Inform patient to
pyelonephriti -Anticoagulants:
Penicillins can vomiting, take drug once daily
s, skin & soft
produce prescription at
melena and
tissue alterations in
platelet abdominal bedtime for best
infections &
aggregation and results.
pain/cramps
gonococcal coagulation tests.
These effects may -Dyspnea 4. Tell the physician
infections.
be additive with
-Rash and what medicines you
Oral follow- anticoagulants.
itching are taking,
up therapy to
-Bacteriostatic
- including those
Unasyn Drugs
(chloramphenicol, Drowsiness/se bought without a
IM/IV.
erythromycin,
dation, prescription and
sulfonamides and
 fatigue/malais herbal medicines,
tetracyclines):
e and
Bacteriostatic before you start
drugs may headache treatment with
interfere with the
-
bactericidal effect Essentiale.
of penicillins; it is
best to avoid 5. Tell the physician
concurrent before taking any
therapy.
new medication
-Methotrexate: while taking this
Concurrent use
with penicillins one, to ensure that
has resulted in the combination is
decreased
clearance of safe.
methotrexate and
a corresponding 6. Do not use the
increase in medicine for other
methotrexate
toxicity. Patients health conditions.
should be closely
monitored.
Leucovorin
dosages may need
to be increased
and administered
for longer periods
of time.

-Probenecid:
Decreased renal
tubular secretion
of ampicillin and
sulbactam when
used
concurrently; this
effect results in
increased and
prolonged serum
concentrations,
prolonged
elimination half-
life and increased
risk of toxicity.
 Generic Name: Lactulose
Brand Name: Contulose

Side Effects/
Classificat Suggested Mode of Contra- Drug Adverse Nursing
ions Dose Actions Indications indications Interactions Reactions Responsibilities
Laxative 30ml OD Produces Contraindicated GI: belching, 1. Asses patient for
- Drug-drug.
HS osmotic in patients on cramps,
constipation abdominal
- Should not be
effect in low- galactose distention, distention, presence
- To prevent used with other
colon. diet flatulence, of bowel sounds
and treat laxatives in the
Resulting diarrhea and normal pattern
hepatic treatment of
distention ENDO: of bowel function.
encephalopa hepatic
promotes Hyperglycemi
thy, encephalopathy 2. Dissolve single
peristalsis. a
including dose packets in 4
Decrease - Anti- infectives
hepatic oz. of water.
blood may diminish
precoma Solution should be
ammonia effectiveness in
and coma I colorless to slightly
build- up treatment of
patients pale yellow.
the causes hepatic
with severe
hepatic encephalopathy 3. Encourage
hepatic
encephalopa patient to use other
disease.
thy, forms of bowel
probably ass - to induce regulation, such as
result of bowel increasing mobility.
bacterial evacuation Normal bowel
degradation in geriatric habits are
which patients individualized and
lowers pH with colonic may vary from 3
of colon retention of times/day to 3
contents. barium and times/wk.
Relieves severe 4. Caution patient
constipation constipation that this medication
, decreases after a may cause belching,
ammonia barium meal flatulence, or
concentratio examination abdominal
n.
- to restore cramping. Health
bowel care professional
movements should be notified if
after this becomes
hemorrhoid botherspme or if
ectomy. diarrhea occurs.
Generic Name: Piracetam
Brand Name: Contulose

Side Effects/
Classificat Suggested Mode of Contra- Drug Adverse Nursing
ions Dose Actions Indications indications Interactions Reactions Responsibilities
Nootropic 1.2 g., Piracetam Stroke, Piracetam is Anxiety,
Drug-drug. 1. Seek the advice of a
1tab ischemia contra-
improves the insomnia,
TID and indicated in health care professional
A single
function of the symptoms patients with irritability, before using.
severe renal case has
neurotransmitter headache,
impairment been 2. Keep Out of Reach of
acetylcholine (renal agitation,
creatinine reported in Children.
via muscarinic nervousness,
clearance of which the
cholinergic less than 20 ml and tremor, are 3. Abrupt suspension of
per minute), concomitant
(ACh) receptors occasionally treatment should be
hepatic (liver) use of
which are impairment and reported. avoided, since this can
to those under Piracetam
implicated in cause a myoclonic or
16 years of age. and thyroid
memory It is also general crisis in certain
contraindicated hormone
processes. myoclonic patients.
in patients with extracts (T3
Furthermore, cerebral 4. The daily dosage (to
haemorrhage + T4) has
Piracetam may be broken down into 2
and in those produced
have an effect with or 3 doses) and length
hypersensitivity confusion,
on NMDA of treatment are to be
to piracetam, irritability
glutamate other established by the
pyrrolidone and sleeping
receptors which doctor, depending on
derivatives or disorders. Its
are involved any of the interaction the state and clinical
excipients.
with learning with other evolution of the patient.
and memory drugs has 5. Piracetam is non-
processes. not been toxic even in high
described. doses. Massive
accidental overdose can
be treated either orally
or intravenously with
forced diuresis or
dialysis in the case of
renal insufficiency. In
the event of overdose or
accidental swallowing,
consult a doctor.
Generic Name: Atorvastatin calcium

Brand Name: Lipitor

Classification Suggested Mode of Indication Contraindication Drug Adverse Effects Nursing Responsibilities
Dose Action Interactions
Antilipemics 80 mg ½ Inhibits - Adjunct to diet to - Contraindicated - Antacids, - CNS: - Teach patient about
tab OD @ HMG-CoA reduce LDL, total in patients cholestyramine, headache, proper dietary
HS – NGT reductase, cholesterol, hypersensitive to cholestipol: asthenia, management, weight
an early apolipoprotein B, drug and in those May decrease insomnia. control, and exercise.
(and rate- and triglyceride with active liver atorvastatin - CV: peripheral Explain their importance
limiting) levels and to disease or level. Monitor edema in controlling high fat
step in increase HDL unexplained patient. - EENT: levels.
cholesterol levels in patients persistent - Cyclosporine, pharyngitis, - Warn patient to avoid
biosynthesis with primary elevations of diltiazem, fibric rhinitis, alcohol.
hypercholesterolem transaminase acid derivatives, sinusitis - Tell patient to inform
ia levels macrolides - GI: abdominal prescriber of adverse
- Heterozygous - Contraindicated (azithromycin, pain, reactions, such as muscle
familial in pregnant and clarithromycin, constipation, pain, malaise, and fever.
hypercholesterolem breastfeeding erythromycin, diarrhea, - Advise patient that
ia women and in telithromycin), dyspepsia, drug can be taken at any
- to reduce the risk women of nefazodone, flatulence, time of day, without
of MI, stroke, childbearing age niacin, protease nausea. regard to meals.
angina, or - Use cautiously inhibitors, - GU: UTI - Use only after diet and
revacularization in patients with verapamil: may - Musculo- other nondrug therapies
procedures in history of liver decrease skeletal: prove ineffective. Patient
patients with disease or heavy metabolism of rhabdomyolysis should follow a standard
multiple risk factors alcohol use HMG-CoA , arthritis, low-cholesterol diet
for CAD but who - Withhold or reductase arthralgia, before and during
don’t yet have the stop drug in inhibitors, myalgia therapy.
disease patients at risk for increasing - Respiratory: - Before treatment,
renal failure toxicity. bronchitis assess patient for
caused by Monitor patient - Skin: rash underlying causes for
rhabdomyolysis for adverse - Other: allergic hypercholesterolemia
resulting from effects and reactions, and obtain a baseline
trauma; in report flulike lipid profile. Obtain
serious, acute unexplained syndrome, periodic liver function
conditions that muscle pain. infection test results and lipid
suggest - Digoxin: May levels before starting
myopathy,; and in increase digoxin treatment and at 6 and
major surgery, level. Monitor 12 weeks after initiation,
severe acute digoxin level or after an increase in
infection, and patient for dosage and periodically
hypotension, evidence of thereafter.
uncontrolled toxicity. - Drug may be given as a
seizures, or - Fluconazole, single dose at any time
severe metabolic, itraconazole, of day, with or without
endocrine, or ketoconazole, food.
Generic Name: Mupirocin

Brand Name: Bactroban

Classification Suggested Mode of Indication Contraindication Drug Interactions Adverse Effects Nursing Responsibilities
Dose Action
- Local anti- Apply Inhibits - Impetigo - Contraindicated - Chlorampenicol: - CNS: - Tell patient to notify
infectives ointment bacterial - Traumatic skin in patients May interfere headache prescriber immediately if
- antibiotic TID protein lesions infected hypersensitive to with the - EENT: condition doesn’t
synthesis by with drug. antibacterial pharyngitis, improve or gets worse in
reversibly staphylococcus - Use cautiously action of rhinitis, 3 to 5 days
and aureus or in patients with mupirocin on sinusitis, - Tell patient not to use
specifically streptococcus burns or large RNA synthesis. burning or other nasal products with
binding to pyogenes open wounds and Monitor patient stinging with mupirocin
bacterial - To eradicate in those with for clinical effect. intranasal use - Warn patient about
isoleucyl nasal colonization impaired renal - GI: taste local adverse reactions
transfer- by methicillin- function because perversion, related to drug use
RNA resistant S. aureus serious renal nausea, - Caution patient not to
synthetase in adult patients toxicity may abdominal pain, use cosmetics or other
and health care occur ulcerative skin products on treated
workers stomatitis area
- Respiratory: - Drug is not for
upper ophthalmic or internal
respiratory tract use
congestion, - Prolonged use may
cough with cause overgrowth of
intranasal use. nonsusceptible bacteria
- Skin: burning, and fungi
pruritus, - Local reactions appear
stinging, rash, to be caused by
pain, erythema polyethylene glycol
with topical use. vehicle
Generic Name: Mannitol

Brand Name: Osmitrol

Classification Suggested Mode of Indication Contraindication Drug Adverse Effects Nursing Responsibilities
Dose Action Interactions
Osmotic - 60 cc x Increases - To prevent - Contraindicated - Lithium: - CNS: seizures, - Tell patient that he may
Diuretics 30 mins. q osmotic Oliguria. in patients with May increase dizziness, feel thirsty or have a dry
4 pressure of - To prevent renal annuria; frank urinary headache, fever mouth, and emphasize
- 20 ml IV glomerular failure pulmonary excretion of - CV: edema, importance of drinking
for 30 filtrate, - To reduce edema; active lithium. thrombophlebitis, only the amount of fluid
mins. now inhibiting intraocular or intracranial Monitor Hypotension, s ordered
- 120 cc q tubular intracranial bleeding; severe lithium level hypertension, - Instruct patient to
4 to run 30 reabsorption pressure dehydration; closely. heart failure, promptly report adverse
mins. of water and - Diuresis in drug metabolic edema; tachycardia, reactions and discomfort
- 100 cc q electrolytes; intoxication previous angina-like chest at I. V. site
4 x 30 drug - Irrigating solution progressive renal pain, vascular - Monitor vital signs,
mins. elevates during transurethral disease or overload including central venous
plasma resection of dysfunction after - EENT: Blurred pressure and fluid intake
osmolality, prostate gland starting drug, vision, rhinitis and output hourly.
increasing including - GI: thirst, dry Report increasing
water flow increasing mouth, nausea, oliguria. Check weight,
into azotemia and vomiting, renal function, fluid
extracellular oliguria; or diarrhea balance, serum and urine
fluid. previous - GU: urine and potassium levels
progressive heart retention daily.
failure or - Metabolic: -To relieve thirst, give
pulmonary dehydration frequent mouth care or
congestion after - Skin: local fluids
drug. pain,urticaria - Drug can be used to
- Other: chills measure GFR
Generic Name: Salbutamol sulfate

Brand Name: Provexel

Classification Suggested Mode of Indication Contraindication Drug Adverse Effects Nursing Responsibilities
Dose Action Interactions
- Anti- I neb with Increasing the - Symptomatic - Contraindicated -Allopurinol Tachycardia, - Tell patient to inhale
asthmatic ambroxol levels of the relief of in patients with palpitations, the smoke release by the
- Broncho for energy bronchospasm in hypersensitivity -Cimetidine flushing, fine nebulization
dilator inhalation producing obstructive to the drug tremor of - Advise patient to
10 gtts + substance airway diseases -Erythromycin skeletal inform the medical team
PNSS TID called cAMP. - Bronchial muscles, if any adverse reactions
Inhibiting asthma, -Flu Vaccine nervousness, occur
PDE the -emphysema tension, - Perform back tapping
enzyme that -chronic -Oral headaches, after nebulization to help
breaks down bronchitis. Contraceptives muscle cramps. expectorate phlegm
cAMP. - Watch out for any
Subsequently, secretions and notify the
this causes physician.
smooth
muscle
relaxation and
broncchodilati
on; also
inhibits
release of
chemical
mediators
such as
histamine
Generic Name: Hexetidine

Brand Name: Bactidol

Classification Suggested Mode of Indication Contraindication Drug Interactions Adverse Effects Nursing Responsibilities
Dose Action
- Antiseptic Hold 15- Inhibit - Minor sore - Contraindicated No known drug - Transient - Tell patient to carefully
mouthwash 20 mL in protein throat in patients interaction numbness & gargle bactidol and
- Anti- the mouth. synthesis by - Halitosis hypersensitive to alteration in avoid swallowing it.
bacterial Swish & binding to a - General oral drug. taste may occur. - Inform patient that he
- Anti- fungal gargle for portion of hygiene - Use cautiously can mix bactidol with
30 sec in the bacterial - Improves in children ages 6 minimal amount of
the ribosome appearance of and below water to reduce its strong
morning mouth tissues taste
& - Protects tooth
evening. surfaces against
Use full formation of
strength. decay acids.

Nursing Theory
Imogene King (Goal attainment theory)
Jean Watson (human caring relationship
theory
NURSING THEORIES
Description
Imogene King's model is a model of three
interacting systems: personal,
interpersonal, and social. In her theory of
goal attainment, she states that client goals
are met through the transaction between
nurse and client. The model can be
applied to all settings. Her model is based
on systems theory but has also been
classified as an interaction model.
The main concept of the theory is
transpersonal human caring, which is best
understood within the concepts of three
ancillary concepts: LIFE, ILLNESS, and
HEALTH.
HUMAN LIFE is defined as spiritual-
mental-physical being-in-the-world, which
is continuous in time and space.
ILLNESS is not necessarily disease. Illness
is subjective turmoil or disharmony with a
person's inner self or soul at some level or
Application to the patient
As health provider we need to learn how to
interact with our patient. We must
encourage them to verbalize feelings in
order for us to provide interventions
necessary to the patient’s condition.
Through a good therapeutic
communication it will give us complete
verification in which it will lead us to a
good attainment.
As a student nurse our goal is to help
persons gain a higher degree of harmony
within the mind, body, and soul which
generates self-knowledge, self-reverence,
self-healing, and self-care. We need to
alleviate that certain kind of illness; thus, it
will lead to the promotion of a good health.
We must also focus on how to care
patient’s who really needs special
attention. And to effectively accomplish
patient’s cooperation we must learn how to
gain trust to them, in the end we can easily
instill hope and cooperation for fast
recovery.
 disharmony within the spheres of the
person, either consciously or
unconsciously.

HEALTH refers to unity and harmony

within the mind, body, and soul.

Dorothy Johnson (behavioral system

model) Johnson states that a nurse should use the
behavioral system as their knowledge base;
comparable to the biological system that
physicians use as their base of knowledge.
The reason Johnson chose the behavioral
system model is the idea that "all the
patterned, repetitive, purposeful ways of
behaving that characterize each person's
life make up an organized and integrated
whole, or a system".
As a nurse, we need to identify our
patient’s coping abilities regarding to
stress. We must also identify such
contributing factors to enable us to provide
nursing care to prevent the occurrence of
such problem and for the patient to meet
his needs,
Date Cues Need Nursing Dx Objective of Care Nursing Interventions Evaluation
S/OBJECTIVE: Impaired At the end of our shift, the 1.) Determine existing condition GOAL MET
A - Hemiparesis A physical patient will be able to affecting level of own ability of April 30, 2009
P noted at the C mobility improved mobility as individual to move After 8 hours
R right side T related to evidenced by: ® To identify causative/ of span of care,
I - absence of I hemiparesis, a.) independent slow contributing factors the patient was
L voluntary V loss of movement of the 2.) Determine degree of able to improve
movements of I balance and extremities perceptual/ cognitive impairment mobility as
3 the extremities, T coordination b.) slow movement of body and ability to follow directions evidenced by:
0, muscle tone, Y and brain from one side to another ® to identify the necessary
body posture, injury interventions to be done a) trying to flex
2 and head E secondary to 3.) Observe movement when extremities
0 position X CVA client is unaware of observation
0 - difficulty E ® to note any incongruencies b) slow
9 ambulating R RATIONALE with reports of abilities movement of
-needs C Due to brain 4.) Assist client reposition the body from
@ assistance when I damage himself frequently on a regular one side to
moving S caused by basis another
2 E stroke its ® to promote ability to move
P resulting independently
M effect is the 5.) Instruct client to move from
P limitation in side to side frequently
A independent, ® to promote ability to move
T purposeful independently and to avoid bed
T physical sores
E movement of 6.) Consult with physical/
R the body or of occupational therapists as
N one or more indicated
extremities ® to develop individual exercise/
mobility program and identify
appropriate adjunctive devices
7.) Identify energy-conserving
techniques for ADL’s.
® limits fatigue, maximizing
participation
Date/time Cues Needs Nursing Objectives/goals Intervention Evaluation
diagnosis
R Impaired verbal Within our 6 1.Monitor patient’s vital signs April 30,
April 30, S/O: O communication hour span of ® serves as baseline data. 2009 @ 9:00
2009 @ - right sided L r/t alteration in care, our patient 2.Determine ability to write. pm
3:00 pm weakness E central nervous will be able to Evaluate musculoskeletal states,
- Aphasia system 2° CVA establish method including manual dexterity (e.g. GOAL MET!
- with NGT R ® Decreased, of ability to hold a pen and write).
- Vital signs E delayed, or communication ® to assist client to establish a Patient was
BP- 130/ L absent ability to in which needs means of communication able to
90 mmHg A receive, can be 3. Obtain a translator/written establish
RR- 25 T transmit, expressed. translation or picture chart method of
bpm I process, and use ® to assist client to establish a communication
PR- 68 O a system of means of communication when in which needs
bpm
N symbols. writing is not possible. can be
TEMP- S Reference: 4. Facilitate hearing and vision expressed.
38.1 °C H Nurse’s Pocket examinations/obtaining necessary
I Guide 10th aids. Assist client to learn and
P edition p. 65 adjust to aids.
By: Doenges, ® for improving the patient’s
P Moorehouse and communication skills
A Murr 5.Establish relationship with the
T client, listening carefully and
T attending to client’s nonverbal
E expressions.
R ® to assist client to establish a
N means of communication
6.Keep communication simple,
using all modes for accessing
information: visual, auditory, and
kinesthetic.
® for the patient to easily
understand messages and relay
nonverbal communication skills
7.Maintain a calm, unhurried
manner. Provide sufficient time
for the client to respond.
® individuals with expressive
aphasia may talk more easily
when they are rested and relaxed.
8.Validate meaning of nonverbal
communication; do not make
assumptions.
® there is a tendency that
Date Cues Need Nursing Dx Objective of Care Nursing Interventions Evaluation
S/OBJECTIVE: S Self- care At the end of our shift, the 1.) Determine existing condition GOAL MET
A - unkempt hair E deficit r/t pain patient will be able to affecting level of own ability of April 30, 2009
P noted L and demonstrate techniques to individual to care for own needs After 5 hours
R -halitosis noted F discomfort meet self- care needs as ® To identify causative/ of span of care,
I - several days - evidenced by: contributing factors the patient’s
L without bathing P RATIONALE a.) verbalization of the 2.) Determine individual watcher was
hygiene as E Pain is a client’s watcher the strengths and skills of the client able to
3 verbalized by R typical importance of maintaining and note whether the deficit is demonstrate
0, the watcher C sensory a good personal hygiene permanent or temporary techniques to
E experience b.) watcher will be able to ® To assess degree of disability meet self- care
2 P that may be demonstrate ways in 3.) Promote client’s watchers needs as
0 T described as maintaining the client’s participation in problem evidenced by:
0 I the unpleasant personal hygiene. identification
9 O awareness of ® To enhance commitment to a) fingernails
N a noxious plan optimizing outcomes well- trimmed
@ - stimulus or 4.) Allow sufficient time for the
S bodily harm. client’s watcher to accomplish b) able to fix
E Individuals task hair with
P L experience ® To assist in dealing with the assistance
M F pain by situation
- various daily 5.) Assist with necessary c.) able to
C hurts and adaptations to accomplish gargle with
O aches, and ADL’s bactidol with
N occasionally ® To aid the client in achieving assistance
C through more task
E serious 6.) Provide privacy during d.) able to
P injuries or personal care activities change clothes
T illnesses, thus, ® To provide privacy to the with assistance
- the practice of client
P self- care 7.) Provide for communication
A activities that among those who are involved in
T an individual caring/ assisting the client
T initiates and ® To enhance coordination and
E perform on continuity of care
R their own 8.) Encourage the family to
N behalf in assist the client in performing
maintaining self- care activities
life, health ® To promote wellness
and well
being is
affected.
 (http://current
nursing.com/n
ursing_theory/
self_care_defi
cit_theory.ht
m)

Date/ Cues Need Nursing Diagnosis Objective of Care Nursing Intervention with Evaluation
Time Rationale
 A S/O: A Activity Intolerance Within our 3 1. Monitor Vital Signs Goal MET!
P C related to right- hours span of ® VS serves as the
R - Right- sided T sided weakness of care, the patient baseline date April 30, 2009 @ 8
I hemiparesis I the body secondary will be able to 2. Note presence of pm
L noted V to Cerebrovascular demonstrate a factors contributing
- With NGT I Accident, infarct, decrease in to weakness. Within our 3 hours
30 noted T left middle cerebral physiological ® to identify span of care the
, - Vital signs: Y artery signs of causative/ patient was able to
2009 BP- 130/ 90 - intolerance as precipitating factors demonstrate
mmHg E ® evidenced by 3. Evaluate current decrease in
@ RR- 25 bpm X Insufficient stable vital signs. limitations/ degree physiological signs
5pm PR- 68 bpm E physiological or of deficit in light of of intolerance as
TEMP- 38.1 R psychological usual status. evidenced by stable
°C C energy to endure or ® provides Vital Signs.
I complete required or comparative
S desired daily baseline BP- 120/90 mmHg
E activities 4. Assist with RR-20 bpm
activities and PR- 68 bpm
P Reference: provide/ monitor Temp- 37 °C
A Nurse’s Pocket client’s use f
T Guide 10th edition p. assistive devices
T 65 ® to protect from
E By: Doenges, injury
R Moorehouse and 5. Provide referral to
N Murr other discipline as
indicated
® To develop
individually
appropriate
therapeutic
regimens.
 6. Encourage to
perform range of
motion exercises.
® to promote
circulation
7. Review
expectations of
client/ Significant
others
® to establish
individual goals
8. Assist client in
learning and
demonstrating
appropriate safety
measures
® to prevent
injuries

Date/Time Cues Needs Nursing Diagnosis Objective/Goal Intervention Evaluation

April 30, S/O: N Hyperthermia r/t release of Within my 1-3 hour 1. Monitor patient’s vital April 30, 2009
2009 - Flushed U endogenous pyrogens as span of care, my signs. @
 skin T evidenced by increase in patient’s body ® serves as baseline
@ - Warm to R temperature above normal temperature will data 8:00 pm
touch I range decrease from 38.1 °C 2. Note chronological and
5:00pm - Irritability T to 36.5-37.5°C. developmental age of GOAL MET
noted I R: Hyperthermia is the client.
- Restlessne O elevation of body temperature ® infants, young Patient’s body
ss noted N above normal range. Most children, and elderly temperature
A often, it results from infection persons are most decreased from
VITAL L somewhere in the body, but it susceptible to damaging 38.1 °C to 36.8
SIGNS: may be caused by other hyperthermia. °C
- conditions (cancer, allergic Environmental factors
BP- reactions, and CNS injuries). and relatively minor
130/ 90 M Macrophages, white blood infections can cause a
mmHg E cells, and injured cells release much higher
RR- 25 bpm T chemical substances called temperature in them.
PR- 68 bpm A pyrogens that act directly on They are also not able to
TEMP- 38.1 B the hypothalamus, causing its protect themselves, and
°C O thermostat to be set to a cannot recognize and/or
L higher temperature. act on symptoms of
I hyperthermia.
C SOURCE: 3. Provide cool/tepid
Nursing Diagnosis Manual by sponge bath
P Doenges, Moorhouse, Murr. ® promotes heat loss by
A evaporation and
T Essentials of Human conduction
T Anatomy and Physiology 4. Limit clothing/dressing
E (page 490) by Elaine Marieb in lightweight, loose-
R fitting clothes.
N ® encourages heat loss
by radiation and
conduction.
5. Cool the environment
with air-conditioning or
fans.
® promotes heat loss by
convection
6. Lavage body cavities
with cold water in
presence of malignant
hyperthermia
® to promote core
cooling
7. Keep clothing and linens
dry.
® to reduce shivering
8. Offer/force plenty of
fluids, even if client is
not thirsty
® to replace fluids lost
through perspiration and
respiration.
9. Maintain bedrest
® to reduce metabolic
demands/oxygen
consumption.

10. Collaborate with

dietician in providing
patient with high-calorie
diet, or parenteral
nutrition
® to meet increased
 metabolic demands
11. Notify physician if
pharmacologic regimen
is inadequate to meet
hyperthermia control
goal.
® to determine if there
is a need to increase
dosage, change
medication or use a
stepped program (e.g.,
switching from injection
to oral route, or
lengthening time
interval between doses).

12. Administer antipyretics,

orally or rectally, as
ordered.
® to aid in reducing
fever
13. Provide supplemental
oxygen as ordered.
® to offset increased
oxygen demands and
consumption.
14. Administer replacement
IV fluids and
electrolytes as ordered.
® to support circulating
volume and tissue
perfusion and to aid in
hydration
 DISCHARGE PLAN

Medicines

 Discuss with the patient and watcher the need to comply with home medications.

® This will help the family and the patient to know the importance and advantage in

complying treatment regimen.

 Explain with them the advantages and disadvantages of strict compliance of

treatment regimen.

® This will ensure and encourage the patient that taking medications will help treat

and prevent recurrence of the disease and for faster recovery.

 Instruct the patient and watcher the right time, right medications, right dosage,

and right route as ordered by the physician.

® This will avoid confusion of the proper drugs that would be taken by the patient.

 Instruct the patient not to skip taking medications and complete the whole course

of medication.

® This will help for an effective action and compliance of the medications and for

faster recovery.

 Remind the patient and watcher the importance of taking consideration of the

foods or other drugs that is contraindicated while taking the medications.

® This will prevent further complications and unnecessary effects to the patient.

 Instruct and warn patients and significant others about the possible effects and

adverse reactions that may occur brought about by taking the medications.
 ® Side effects and adverse reactions from the medications will sometimes lead into

another occurrence of complication or disease. This will also facilitate proper medical

assistance.

 Remind them to take the drugs properly and taking note of the expiration date

before taking the medication.

® This will ensure good compliance of the medications to be taken and to prevent

accident poisoning.

 Encourage the patient not to take medications not prescribed by the physician.

® Non-prescribed drug may contain antagonistic or synergistic effect.

 Instruct the patient not to stop the medication abruptly or adjust the dosage

without prescription of the physician.

® Stopping the medication abruptly or adjusting the dosage would not take the effect

or action of the medication.

 Instruct the family to properly store and handle the medications so as not to let

children accidentally get hold of it.

® This will prevent accident of drug poisoning.

Exercise/Environment

 Encourage the patient to perform light exercises such as walking and jogging.

® Exercise helps reduce cholesterol levels in the biliary tract, which could help

prevent gallstones.

 Avoid heavy exercises.

® To prevent the risk of tearing the incision site and also to prevent body fatigue.
Treatment

 Explain the purpose of the treatment and why it is continued at home.

® This will help the patient and family to be oriented about the treatment and this will

help her understand about the importance of taking the prescribed drugs for faster

recovery in the disease process. To also make them aware that the treatment is not

only done in the hospital but it should be continued at home.

 Explain to the family the condition of the patient and give them factual

information.

® To have better understanding of the condition of the patient and to make

appropriate action of the disease.

 Direct and instruct the watcher to give the medication or assist the patient

according to the medication regimen.

® Giving the medication and assisting the patient accordingly will have good

compliance of the medications and will give sufficient effect to the patient’s

condition.

 Emphasize the importance of recognizing any sign of unusuality.

® To give appropriate intervention.

Health Teaching/Hygiene

 Encourage and advice the patient and family members to practice proper hand

washing before and after eating.

® Proper hand washing will prevent the spread of microorganisms.

  Instruct patient to do activities of daily living.

® To promote good health and prevent infection. It also increases the sense of

wellness, which is very much needed in the therapeutic process.

Out-Patient Referral

 Encourage patient and family to have a regular check up with their physician

® To monitor health status and conditions. This will help recognize any alterations in

the body.

 Advice patient and family to follow doctor’s order comply with the doctor’s

advice and follow what is stated in the written discharge instruction.

® Following the doctor’s advice and complying will help achieve the success of the

treatment coarse and will help for the immediate recovery of the patient.

 Encourage the patient and the family to immediately report any unusualities

regarding the patient’s condition.

® Signs of unusualities will indicate the occurrence of the disease and reporting it

immediately to the health care providers will immediately give enough attention to

treat the said complaint.

Diet

 Avoid crash diets or a very low intake of calories — less than 800 calories a day.

® Losing weight too quickly is associated with an increased risk of gallstones.

 Choose a low-fat, high-fiber diet that emphasizes fresh fruits, vegetables and

whole grains. Reduce the amount of animal fat, butter, margarine, mayonnaise

and fried foods in daily meal.

® A high-fiber, low-fat diet helps keep bile cholesterol in liquid form. Do not cut out

fats abruptly or eliminate them altogether, as too little fat can also result in gallstone

formation.

 Eat regular meals, 5 or 6 small meals per day.

® This helps to avoid overloading the digestive system and allows the body more

time to digest any fats.

PROGNOSIS
 Poor(1) Fair(2) Good(3) Justification
Onset of illness / Mr. Eks’ onset of illness is
poor because his illness was
sudden.
Duration of / Prior to Mr. Eks’ admission at
illness Limso Hospital, he stayed 4
days at Cateel Hospital and
during our last day of duty at
Limso it was his 10th day at
the hospital. He has been
hospitalized for about two
weeks already.
Precipitating / Most of the precipitating
factor factors are present in Mr. Eks.

Predisposing / Almost half of the

factor Predisposing factors are
present in the patient.
Willingness to / The patient is willing to take
follow and comply with his
treatment treatment regimen because he
regimen knows it is for her own
benefit.
Family support / During our duty in the
hospital, his family was
always there and did not
leave him alone.

TALLY
Poor: (1 x 4) = 4
Fair: (2 x 0) = 0
Good: (3 x 2) = 6
Total: 10/6 = 1.7
Ranges:
1.0 – 1.5 = POOR

1.5 – 2.5 = FAIR

2.5 – 3.0 = GOOD
Impression:
 After evaluating our client, we have rated the client’s prognosis as FAIR. Even
though half of his body can no longer regain its previous functions Mr. Eks still can have
a normal life after seeking for medical assistance. Also the willingness of the client in
taking his medications and supportive family will help her cope with the situation
productively.

Recommendation

For the family:

 We recommend that the family will still continue to give the patient love and

support. It could still help the patient survive when there is a strong bond of relationship

within the family. The family must learn to understand the patient’s situation. They must

also be aware of some medications that are really needed for the patient. They must find

ways and means to comply with such certain meds, because if patient is left untreated

then it will lead to certain complications that will even more add up to the expected

amount.

For the patient:

The patient should be aware with his condition. He must be well oriented of the

facts about the things that she should be alarmed of. We recommend that the patient will

be complying all the medications given to him by the physician. And as a patient he must

follow all the doctor’s guidelines to him. He must discipline himself to all the things that

must be avoided. Also, patient must learn the importance of proper hygiene in order to

lessen other possible infections.

For the community:

CVA or stroke is not always preventable for those at risk, however, steps can be

taken to lower the chance to develop and to delay the possible outcome. That’s why we

want to recommend that we must stay healthy as much as possible.

BIBLIOGRAPHY

• Blackwell’s Dictionary of Nursing

• Contemporary Medical Surgical Nursing
• Smeltzer, S. & Bare, B. (2004). Bruner & Suddarth’s Textbook of Medical
Surgical Nursing. (10th Ed.) Philadelphia: Lippincott Williams Wilkins.
• Cotran, R., Kumar, V., & Robbins, S. (1994). Robbins Pathologic Basis of
Disease. (5th Ed.) Philadelphia:W.B. Saunders Company.
• Gould, B.E. (2006). Pathophysiology for the Health Professions. (3rd ed).
Philadelphia: Saunders Elsevier
• Monahan, F.D et al. (2007). Phipps’ Medical-Surgical Nursing. Health and Illness
Perspectives. Canada: Mosby Elsevier
• Nelms, M., Sucher, K., Long, S. (2007). Nutrition, Therapy & Pathophysiology.
Australia: Thomson Wadsworth.
• Porth, C.M. (2002). Pathophysiology. Concepts of Althered Health States. (6th
ed). Lippincott Williams and Wilkins
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