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Patient #6: Cerebrovascular Damage/ Bleed

M 48
DIAGNOSIS ANALYSIS GOAL NURSING RATIONALE EVALUATION
INTERVENTIONS
Risk for Impaired skin A state in which a persons Within the entire – Implement a – A schedule that The skin of the client
integrity related to skin is at risk from being shift the patient’s post turning does not remain to be intact
immobilization altered. skin will maintain to schedule, interfere with
be intact as restricting time the patients
O: evidenced by no in one position schedule is to be
redness on bony to 2 hrs. or less followed.
The patient is lying on
prominence. and customizing
bed.
the schedule to
Wearing adult diaper patient’s routine

With NGT
S: – Maintain
patient’s
SO verbalized “na- functional body
stroke kasi yan, ngayon alignment
nga lang yan
nagsimulang
magkamalay eh.”
– Clean dry and
moisturize the – To reduce
skin, specially friction
M: over bony
prominence
BP 140/80
PR 57
RR 17
Temp 36.8
Drug Dosage Classification Indication Contraindication Side Effects Nursing
Name Responsibilities
Simvasta 40mg/tab 1 Inhibits HMG- Indications Contraindicated CNS: Headache, asthenia, – Assess nutrition:
tin tab OD at CoA reductase, with allergy to sleep disturbances fat, protein,
hs (p.o.) the enzyme Adjunct to diet in the treatment of simvastatin, fungal carbohydrates
that catalyzes elevated total cholestrol and LDL byproducts, GI: Flatulence, diarrhea, – Monitor bowel
the first step in cholesterol with primary pregnancy, abdominal pain, cramps, pattern daily
the cholesterol hypercholesterolemia (types IIa and lactation. constipation, nausea, – Monitor
synthesis IIb) in those unresponsive to dietary dyspepsia, heartburn, liver triglycerides,
pathway, restriction of saturated fat and failure cholesterol
resulting in a cholesterol and other baseline
nonpharmacologic measures Respiratory: Sinusitis,
decrease in throughout
pharyngitis
serum treatment
To reduce the risk of coronary
cholesterol, Other: Rhabdomyolysis,
disease, mortality, and CV events,
serum LDLs, acute renal failure,
including stroke, TIA, MI and
and either an arthralgia, myalgia
reduction in need for bypass Precautions:
increase or no
surgery and angionplasty in patients
change in Past liver disease,
with coronary heart disease and
serum HDLs. alcoholism, severe
hypercholesterolemia
acute infections,
trauma, severe
metabolic disorders,
electrolyte
imbalances, elderly,
renal disease
Lactulose 80 cc BID Gastrointestina prevention and tx of portal- diarrhea – Effects are seen in
l agent, systemic encephalopathy (PSE), 24-48 hrs
hyperosmotic including stages of hepatic precoma – Do not self
laxative and coma, and by prescription for medicate with
relief of chronic constipation another laxative
because of slow
onset
– Notify Dr if
diarrhea persists
for more than 24
hrs, could be a
sign of overdose,
and need for med
adjustment

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