A

CASE STUDY
ON
CEREBROVASC
ULAR

ACCIDENT
Submitted by:
Myera Angelica G. Ancheta
Ma. Enrica M. Pattaguan
BSN-3, RLE-35

Submitted to:
Miss Gladys Mae
Pagunuran, RN
Clinical Instructor

Introduction
Cerebrovascular Accident
A cerebrovascular accident is also called a CVA, brain attack, or
stroke. It occurs when blood flow to a part of the brain is suddenly
stopped and oxygen cannot get to that part. This lack of oxygen may
damage or kill the brain cells. Death of a part of the brain may lead to
loss of certain body functions controlled by that affected part.
A CVA may be caused by any of the following:

A piece of fatty plaque (debris) that is formed in a blood vessel

breaks away and flows through the bloodstream going to the
brain. The plaque blocks an artery which causes a stroke. This is
called an embolic stroke.

A thrombus (blood clot) formed in an artery (blood vessel) and

blocked blood flow to the brain. This is called a thrombotic
stroke.

A torn artery in the brain, causing blood to spill out. This is called
a cerebral hemorrhage or hemorrhagic stroke. It often results
from high blood pressure.

Blockage of certain small blood vessels inside the brain.

The following factors may put you at a higher risk of having a

CVA:

Cigarette smoking, cocaine use, or drinking too much alcohol.

Diabetes (high blood sugar).

You or a close family member has had a stroke.

Atherosclerosis (hardening of the arteries) or fatty cholesterol

deposits on artery walls.

Heart disease, such as coronary artery disease.

High blood cholesterol (fat).

High blood pressure.

Multiple brain injury (vehicular accident)

Signs and symptoms of a stroke depend upon the part of the brain
affected and how much damage occurred. During a CVA, you may have
numbness (no feeling), tingling, weakness, or paralysis (cannot move)
on one side of the body. You may have trouble walking, swallowing,
talking, or understanding. Your vision (sight) may be blurred or
doubled. You may have a severe headache, feel dizzy, confused, or

pass out. These signs or symptoms may appear within minutes or

hours.
You may have any of the following tests to diagnose CVA:

CT scan:
o

This is also called a CAT scan. A special x-ray machine uses

a computer to take pictures of your brain. It may be used
to look at bones, muscles, brain tissue, and blood vessels.

You may be given dye before the pictures are taken. The
dye is usually given in your IV. The dye may help your
caregiver see the pictures better. People who are allergic to
iodine or shellfish (lobster, crab, or shrimp) may be allergic
to some dyes. Tell the caregiver if you are allergic to
shellfish, or have other allergies or medical conditions.

Magnetic resonance imaging

o

Using magnetic waves, this test, also called an MRI, takes

pictures of your head. An MRI may show the cause of a
CVA.

Carotid ultrasonography

Arteriography

Treatment of a CVA depends upon the type of stroke:

Ischemic stroke: An ischemic stroke includes strokes caused by

a blockage in a blood vessel.
o

Anticoagulant medicine: Treatment for an ischemic

stroke includes anticoagulant medicines which are also
called blood thinners. This medicine group keeps clots from
forming in the blood.

Antiplatelet aggregating medicine: These medicines

interact with platelets to prevent blood clots from forming.
Platelets are a type of blood cell that join to form clots.

Thrombolytic medicine: This medicine group is used in a

stroke caused by a clot in a blood vessel. Thrombolytics
break apart clots and restore blood flow.

Hemorrhagic (bleed) stroke: This type of stroke may require

surgery.

To prevent CVA the following measures are to be followed:

Take your high blood pressure medicine regularly.

Do not smoke or drink too much alcohol. Alcohol is found in beer,

wine, liquor, like vodka or whiskey, and other adult drinks.
Different people have different ideas about what too much

means. It is important to remember that how often you drink is

as important as how much you drink.

If you have atrial fibrillation (an irregular or fast heart beat), you
may need to take antithrombotic medicine. Having a recent heart
attack may also require you to take antithrombotics.

Keep your blood cholesterol level in a normal range. Eat foods

low in fat to decrease the risk of developing plaque (fatty
deposits) in your blood vessels. If you have hyperlipidemia (high
blood cholesterol level), talk to your caregiver about ways to
lower it.

Monitor and control your blood sugar level if you have diabetes.

Patients Profile
Name: MCI
Sex: Male
Age: 17
Date of Birth: April 22, 1990
Place of Birth: Centro West, Buguey Cagayan
Address: Centro West, Buguey Cagayan
Civil Status: Single
Nationality: Filipino
Occupation: Student
Religion: Roman Catholic
Dialect: Ilokano, Tagalog, English
Educational Attainment: College UnderGraduate (BS in Chemical
Engineering)
Date of Admission: September 3, 2007
Time of Admission: 6:30 P.M.
Place of Admission: Saint Paul Hospital
Attending Physician: Dr. Domingo Matammu
Chief Complaint: Vehicular Accident
Admitted per: stretcher
Admitting Diagnosis: Multiple Physical Injury secondary to vehicular
accident
Final Diagnosis: Cerebrovascular Accident
Subarachnoid Hemorrhage
Cerebral Edema
Multifocal Hemorrhagic Contussion Left Frontal and
Left Parietal Area
Initial Vital Signs:
Temperature: 36.90C
Pulse Rate: 89 bpm
Respiratory Rate: 28 cpm
Blood Pressure: 130/80 mmHg

Nursing History
History of Present Illness:
Last September 1, 2007 at 10:30 pm, the patient was riding on a
scooter with his friend. They were on their way to their boarding house
when they met an accident in Pengue, Tuguegarao City. A van whose
driver was then drunk hit them.
They were brought to CVMC and were admitted to the ICU.
Unfortunately, his companion died. The patient stayed in the said
hospital for 2 days. However, due to lack of equipments, his parents
decided to transfer him to St. Paul Hospital last September 3, 2007 at
around 6:30 pm. He was again admitted to the ICU and stayed there
for 1 week. After making through the critical stage, he was then
transferred to room of choice last September 11, 2007.
According to the SO, the patient has manifested an improvement
in his condition. He is able to perform ROM exercises and participate
during his therapy sessions. The patient was also able to respond to
stimulus and to questions by giving cues such as lifting his arms
whenever he agrees to something.

History of Past Illness:

According to SO, the patient has not acquired any serious illness
before. It was his first time to be hospitalized. In addition, the patient
had completed all the necessary immunizations; however, he has an
allergy on meat. He had consulted a doctor regarding this and was
given medications for it (vitamin B complex). He does not have any
known allergies on any medications.

History of Family Illness:

According to the SO, the patients grandmother on his father side
suffered from hypertension. His mother has an asthma but it is not
severe.
Aside from these, they do not have any known geneticallyinherited diseases.

Anatomy and Physiology

of the

Central Nervous System

The central nervous system (CNS) represents the largest part of the
nervous system, including the brain and the spinal cord. Together with
the peripheral nervous system, it has a fundamental role in the control
of behavior. The CNS is contained within the dorsal cavity, with the
brain within the cranial subcavity, and the spinal cord in the spinal
cavity. The CNS is covered by the meninges. The brain is also
protected by the skull, and the spinal cord is also protected by the
vertebrae.
Function:
Since the strong theoretical influence of cybernetics in the fifties, the
CNS is conceived as a system devoted to information processing,
where an appropriate motor output is computed as a response to a
sensory input. Yet, many threads of research suggest that motor
activity exists well before the maturation of the sensory systems and
then, that the senses only influence behavior without dictating it. This
has brought the conception of the CNS as an autonomous system.

Development:
In the developing fetus, the CNS originates from the neural plate, a
specialised region of the ectoderm, the most external of the three
embryonic layers. During embryonic development, the neural plate
folds and forms the neural tube. The internal cavity of the neural tube
will give rise to the ventricular system. The regions of the neural tube
will differentiate progressively into transversal systems. First, the

whole neural tube will differentiate into its two major subdivisions:
brain (rostral/cephalic) and spinal cord (caudal). Consecutively, the
brain will differentiate into prosencephalon and brainstem. Later, the
prosencephalon will subdivide into telencephalon and diencephalon,
and the brainstem into mesencephalon and rhombencephalon.
The brain of all vertebrates develops from three swellings at the
anterior end of the neural canal of the embryo. From front to back
these develop into the

forebrain (also known as the prosencephalon)

midbrain (mesencephalon)

hindbrain (rhombencephalon)

The brain receives nerve impulses from

the spinal cord and

12 pairs of cranial nerves

The Hindbrain
The main structures of the hindbrain (rhombencephalon) are the

medulla oblongata

pons and

cerebellum

Medulla oblongata
The medulla looks like a swollen tip to the spinal cord. Nerve impulses
arising here

rhythmically stimulate the intercostal muscles and diaphragm

making breathing possible

regulate heartbeat

regulate the diameter of arterioles thus adjusting blood flow.

The neurons controlling breathing have mu () receptors, the receptors

to which opiates, like heroin, bind. This accounts for the suppressive
effect of opiates on breathing. Destruction of the medulla causes
instant death.
Pons
The pons seems to serve as a relay station carrying signals from
various parts of the cerebral cortex to the cerebellum. Nerve impulses
coming from the eyes, ears, and touch receptors are sent on the
cerebellum. The pons also participates in the reflexes that regulate
breathing.
The reticular formation is a region running through the middle of the
hindbrain (and on into the midbrain). It receives sensory input (e.g.,
sound) from higher in the brain and passes these back up to the

thalamus. The reticular formation is involved in sleep, arousal (and

vomiting).
Cerebellum
The cerebellum consists of two deeply-convoluted hemispheres.
Although it represents only 10% of the weight of the brain, it contains
as many neurons as all the rest of the brain combined.
Its most clearly-understood function is to coordinate body movements.
People with damage to their cerebellum are able to perceive the world
as before and to contract their muscles, but their motions are jerky and
uncoordinated.
So the cerebellum appears to be a center for learning motor skills
(implicit memory). Laboratory studies have demonstrated both longterm potentiation (LTP) and long-term depression (LTD) in the
cerebellum.
The Midbrain
The midbrain (mesencephalon) occupies only a small region in humans
(it is relatively much larger in "lower" vertebrates). We shall look at
only three features:

the reticular formation: collects input from higher brain centers

and passes it on to motor neurons.

the substantia nigra: helps "smooth" out body movements;

damage to the substantia nigra causes Parkinson's disease.

the ventral tegmental area (VTA): packed with dopaminereleasing neurons that
o

are activated by nicotinic acetylcholine receptors and

whose projections synapse deep within the forebrain.

The VTA seems to be involved in pleasure: nicotine,

amphetamines and cocaine bind to and activate its dopaminereleasing neurons.
The midbrain along with the medulla and pons are often referred to as
the "brainstem".
The Forebrain
The human forebrain (prosencephalon) is made up of

a pair of large cerebral hemispheres, called the telencephalon.

Because of crossing over of the spinal tracts, the left hemisphere
of the forebrain deals with the right side of the body and vice
versa.

a group of unpaired structures located deep within the cerebrum,

called the diencephalon.

Diencephalon
We shall consider 4 of its structures: the

Thalamus.
o

All sensory input (except for olfaction) passes through it on

the way up to the somatic-sensory regions of the cerebral
cortex and then returns to it from there.

signals from the cerebellum pass through it on the way to

the motor areas of the cerebral cortex.

Lateral geniculate nucleus (LGN). All signals entering the

brain from the optic nerves enter the LGN and undergo some
processing before moving on the various visual areas of the
cerebral cortex.

Hypothalamus.

The seat of the autonomic nervous system. Damage to the

hypothalamus is quickly fatal as the normal homeostasis of
body temperature, blood chemistry, etc. goes out of
control.

The source of 8 hormones, two of which pass into the

posterior lobe of the pituitary gland.

Posterior lobe of the pituitary.

Receives
o

antidiuretic hormone (ADH) and

oxytocin from the hypothalamus and releases them into

the blood.

The Cerebral Hemispheres

Each hemisphere of the cerebrum is subdivided into four lobes visible
from the outside:

frontal

parietal

occipital

temporal

Hidden beneath these regions of cerebral cortex are the

olfactory bulbs; they receive input from the olfactory epithelia.

striatum; it receives input from the frontal lobes and also from
the limbic system (below). At its base is the

nucleus accumbens (NA).

The pleasurable (and addictive) effects of amphetamines,
cocaine, and perhaps other psychoactive drugs seem to depend

on their producing increasing levels of dopamine at the synapses

in the nucleus accumbens (as well as the VTA).

limbic system; it receives input from various association areas

in the cerebral cortex and passes signals on to the nucleus
accumbens. The limbic system is made up of the:
o

hippocampus. It is essential for the formation of long-term

memories.

amygdala
The amygdala appears to be a center of emotions (e.g.,
fear). It sends signals to the hypothalamus and medulla
which can activate the flight or fight response of the
autonomic nervous system.
In rats, at least, the amygdala contains receptors for

vasopressin
whose
activation
increases
aggressiveness and other signs of the flight or fight
response;

oxytocin whose activation lessens the signs of stress.

The amygdala receives a rich supply of signals from the

olfactory system, and this may account for the powerful
effect that odor has on emotions (and evoking memories).
The Extracellular Fluid (ECF) of the Central Nervous System
The cells of the central nervous system are bathed in a fluid that differs
from that serving as the ECF of the cells in the rest of the body.

The fluid that leaves the capillaries in the brain contains far less
protein than "normal" because of the blood-brain barrier, a
system of tight junctions between the endothelial cells of the
capillaries. This barrier creates problems in medicine as it
prevents many therapeutic drugs from reaching the brain.

cerebrospinal fluid (CSF), a secretion of the choroid plexus. CSF

flows uninterrupted throughout the central nervous system
o

through the central cerebrospinal canal of the spinal cord

and

through an interconnected system of four ventricles in the

brain.

CSF returns to the blood through veins draining the brain.

The Spinal Cord
31 pairs of spinal nerves arise along the spinal cord. These are "mixed"
nerves because each contain both sensory and motor axons. However,
within the spinal column,

all the sensory axons pass into the dorsal root ganglion where
their cell bodies are located and then on into the spinal cord
itself.

all the motor axons pass into the ventral roots before uniting with
the sensory axons to form the mixed nerves.

The spinal cord carries out two main functions:

It connects a large part of the peripheral nervous system to the

brain. Information (nerve impulses) reaching the spinal cord
through sensory neurons are transmitted up into the brain.
Signals arising in the motor areas of the brain travel back down
the cord and leave in the motor neurons.

The spinal cord also acts as a minor coordinating center

responsible for some simple reflexes like the withdrawal reflex.

The interneurons carrying impulses to and from specific receptors and

effectors are grouped together in spinal tracts.
Crossing Over of the Spinal Tracts
Impulses reaching the spinal cord from the left side of the body
eventually pass over to tracts running up to the right side of the brain
and vice versa. In some cases this crossing over occurs as soon as the
impulses enter the cord. In other cases, it does not take place until the
tracts enter the brain itself.

Laboratory Examination
Cranial Study
September 2, 2007
Plain axial tomographic sections of the head show multiple
patchy hyperdense foci in the left frontal and left parietal cortical or
subcortical areas.
The interhemispherid fissure is hyperdense.
The ventricles are unenlarged.
The midline structures are undisplaced.
The sulci and cisterns are effaced.
The brainstem, sellar region and posterior fossa do not appear
unusual.
There is partial opacification of the bilateral sphenoid sinuses.
The rest of the paranasal sinuses, included orbits and bony
calvarium appear unremarkable. Negative for fracture.
There is moderate extracalvareal soft tissues swelling of the right
parietal area.
Impression:
Multifocal Hemorrhagic Contusion, Left Frontal and Left Parietal
areas
Subarachnoid Hemorrhage
Cerebral Edema
Sphenoid Hemosinuses
Extracalvareal soft tissue swelling, Right Parietal area
X-Ray of the Cervical Spine APL Views
September 3, 2007
Atlas-dens interval is intact.
Vertebral height and disc spaces are intact.
Prevertebral space is maintained.
Normal lordotic curvature is preserved.
Negative for listhesis.
There is note of extensive subcutaneous emphysema in the neck
area.
Impression:
Negative for fracture or dislocation.
Subcutaneous emphysema as described.
An endotracheal tube is seen in placed.
X-Ray of the Right Arm APL Views
September 3, 2007
Negative for fracture or dislocation.
Joint spaces are intact.
No evidence for soft tissue swelling.
X-Ray of the Right Forearm APL Views
September 3, 2007

Negative for fracture or dislocation.

Joint spaces are intact.
No evidence for soft tissue swelling.
Impression:
Negative for fracture or dislocation.
X-Ray of the Thoracic Cage AP View
September 3, 2007
Negative for fracture in this views.
The visualized lung fields and dorsal spine are unremarkable.
Impression:
Unremarkable Study.
X-Ray of the Pelvis AP View
September 3, 2007
Negative for fracture or dislocation.
Joint spaces are intact.
Impression:
Unremarkable Study
Chest X-Ray AP View
September 3, 2007
The lung fields are clear.
Heart is normal in size.
Diaphragm and sinuses are normal.
Intact bony thorax.
An endotracheal tube is seen with its tip at T4 and T5 level.
Impression:
Normal Chest Study.
Endotracheal tube as described.
X-Ray of the Chest AP View
September 4, 2007
Follow-up study (AP view) in comparison to the one done last
09/03/07 (AP view) shows no evidence of pneumothorax and
pnuemomediastinum formation. The endotracheal tube is still seen
with its tip at T4 level. The rests of the chest findings remain the same.
Cranial CT Scan
September 4, 2007
Follow up plain CT scan of the brain in comparison to the one
done last 09/02/07 (Plain brain study only) shows no significant interval

change in the size of the previously noted hyperdense foci in the

superior left frontal lobe (intraparenchymal and left temporal cortical or
sulci cortical hematoma or subarachnoid hematoma). There is now new
punctate hyperdense focus in the right superior frontal lobe (petechial
hemorrhage). The small hyperdense focus (subarachnoid hemorrhage)
in the interhemispheric area is unchanged. There is now slight
widening of the bifrontal subdural space suggestive of the subdural
hygroma. There is slight resolution of the cerebral edema. The rests of
the brain findings remain the same.
X-Ray of the Chest AP View
September 7, 2007
Follow-up in comparison with the previous study dated 09/04/07,
shows clear lung study.
The heart is magnified.
The endotracheal tube is in site with its tip 1 cm. from the carina.
The lefthemidiaphragm and costophrenic sulcus are obscured by
the overlying cardiac silhouette.
The rests of the findings are unenlarged.
Previous impressions are maintained.
Cranial CT Scan
September 17, 2007
Follow up plain CT scan of the brain in comparison to the one
done last 09/10/07 (Plain CT scan of the brain) shows almost complete
resolution of the superior left frontal lobe by heperdensities (resolving
contusion-hematoma). There is now complete resolution of the left
temporal cortical hyperdensity (resolved contusion-hematoma). No
new lesion or hematoma seen. The rests of the brain findings remain
the same.

Blood Gas and Acid Base Report

Examination Requested: ABG
Blood taken:
Sample Blood;
Arterial Blood
Date: September 3, 2007

Blood Gas

Normal
Results

Actual Results

Analysis

pH

7.35-7.45

7. 489

Alkalosis

PCO2

35-45

25.4 mmHg

Respiratory
alkalosis

PO2

75-100

199.6 mmHg

imbalance
between O2
supply and
demand

HCO3

22-27

19.1 mmol/L

Metabolic
acidosis

TCO2

22-27

19.9 mmol/L or
vol%

SPO2

95-100%

99.6%

Respiratory
alkalosis

Normal

Blood Gas and Acid Base Report

Examination Requested: ABG
Blood taken:
Sample Blood;
Arterial Blood
Date: September 10, 2007
Data for BGAB Analysis:
FiO2 21.0%
Temp 370C

Blood Gas

Normal
Results

Actual Results

pH

7.35-7.45

7. 394

Normal

PCO2

35-45

17.5 mmHg

Respiratory
alkalosis

Analysis

PO2

75-100

188.4 mmHg

imbalance
between O2
supply and
demand

HCO3

22-27

10.5 mmol/L

Metabolic
acidosis

TCO2

22-27

11.0 mmol/L or
vol%

Respiratory
alkalosis

SPO2

95-100%

99.5%

Normal

Blood Chemistry Report

Examination Requested: Na, K
Examination

Date

Normal
Results

Actual
Results

Analysis

Sodium

09-03-07

135-155
mmol/L

148.3
mmol/L

Normal

09-06-07

135-155
mmol/L

149.0
mmol/L

Normal

09-03-07

3.6-5.5
mmol/L

3.54 mmol/L

Hypokalemia,
due to
alkalosis

09-06-07

3.6-5.5
mmol/L

3.40 mmol/L

Hypokalemia,
due to
alkalosis

Potassium

Hematology Report
Examination Requested: CBC, BT

Examination

WBC count

Hemoglobin

Hematocrit

Date

Normal
Findings

Actual
Findings

09-03-07

5-10^9/L

10.5

09-06-07

5-10^9/L

11.7

09-03-07

13.018.0g/dL

11.2

09-06-07

13.018.0g/dL

10.5

09-03-07

39.0-54.0%

34

09-06-07

39.0-54.0%

32

09-03-07

0.60-0.70

0.75

09-06-07

0.60-0.70

0.87

0.20-0.30

0.25

0.20-0.30

0.13

Analysis
Abnormal =
Due to
infection,
tissue
necrosis
Abnormal =
Due to
infection,
tissue
necrosis
Abnormal =
Due to
hemorrhage
Abnormal =
Due to
hemorrhage
Abnormal =
Due to
hemorrhage
Abnormal =
Due to
hemorrhage

Differential
Count
-Segmenters

Lymphocytes

09-03-07

09-06-07

Abnormal =
Due to
presence of
infection
Abnormal =
Due to
presence of
infection
Normal
Abnormal =
Due to
presence of
infection

Urinalysis Report
September 5, 2007

Examination

Normal
Findings

Actual
Findings

Analysis

Color

Straw-dark
yellow

Yellow

Normal

Transparency

Transparent

Clear

Normal

Reaction

4.5-8.0

8.0

Normal

Specific
Gravity

1.010-1.030

1.010

Normal

Sugar

Negative

Negative

Normal

Protein

Trace

Trace

Normal

Microscopic Examination
Squamous Epithelial cells:
Red Blood Cells:
PLS Cells:
Bacteria:

Occasional
Numerous
2-4
Occasional

Bacteriology Spec. Exam. Report

Date: September 19. 2007
Specimen: Blood
Examination Requested: Blood C/S
Final Report: No growth after 7 days of incubation.

Glasgowcoma Scale
Date

Total

09-03-07

09-04-07

09-05-07

09-06-07

09-07-07

09-08-07

09-09-07

09-10-07

10

09-11-07

10

09-12-07

10

09-13-07

10

09-14-07

10

09-15-07

11

09-16-07

11

09-17-07

11

09-18-07

11

Analysis: The patient is stupurous. A score of 8 or less in the

Glasgowcoma scale indicates of head injury.Gordons 11 Health

Functional Pattern

Health Perception-Health Management Pattern

Before Hospitalization:
The patients mother stated that being healthy is free from
sickness and the absence of disease.
She perceived that her child is healthy in his own way,
They use Biogesic, Paracetamol, Alaxan and other drugs
which they know their actions whenever one of the family
members is not feeling well.
They refer to medical institution, whenever one of the family
members gets sick.
The patient doesnt have any vices.
The patient is a student, thus, his mother always reminds him
to take good care of his health.
During Hospitalization:
The patients mother perception of her childs health is poor,
but she sees it as a blessing to them though it is one of their
hardest trials that she ever met.
They manage their childs health by following the medical
treatment given by the health care providers.
Nutrition-Metabolic Pattern
Before Hospitalization:
He eats thrice a day with adequate amount of food.
He has no allergies on all foods except for meat. Thus, he was
given a treatment for it, the doctor had given him Vitamin B
complex
He has a good appetite.
Drinks 6-8 glasses a day.
He drinks milk early in the morning, take snacks in between
meals.
He has no difficulty in swallowing or ingesting foods.
During Hospitalization:
The patient is given an osteorized feeding. Last September 3,
2007 he was given an OF of ensure 200cc/NGT every 4 hours.
Then it was shifted to 2400kcal/day containing CHON=
105grm/day, CHO= 355grm/day and Fats= 68grm/day last
September 5, 2007. It was given in 6 equal feedings per day.
Last September 18, 2007, he was again given an OF
containing 5 scoops of ensure every 2 hours.

Elimination Pattern
Before Hospitalization:
He urinates 4-5 times a day with the amount of at least 700
ml a day and has a yellow amber color of urine.
He has no difficulty in urinating.
He usually defecates early in the morning with a consistency
of brownish in color and semi-solid. But this depends on the
food eaten by him.
He has no difficulty in defecating.
He does not use any laxatives and other stool softeners.
During Hospitalization:
The patient voids through a condom catheter connected to a
urine bag with an output of 630 mL every 8 hours.
He has a difficulty in moving his bowel, thus, is given
lactulose, a laxative in order to alleviate this condition.
Activity-Exercise Pattern
Before Hospitalization:
He wakes up as early as 5:00 in the morning. This is his usual
time. But since he is a student, sometimes he also does
studying and her mother stated that he loves to review early
in the morning.
He also enjoys listening to music and loves to dance.
Playing ball games is one of his hobbies also.
During Hospitalization:
His activity was lessened due to present condition.
He is always at bed lying, and then after waking up, he sleeps
again due to present condition.
His level of consciousness was greatly reduced and his mental
status was altered.
He can only perform limited ROM exercises.
Sleep-Rest Pattern
Before Hospitalization:
He sleeps 6-7 hours a day. But this depends on his activity
since he is a student.
Reading helps him fall asleep easily.
He is not using and sleeping pills.
He is used to have 2 pillows when sleeping.
He usually takes a nap in the afternoon for at least 45
minutes.
He doesnt have any sleeping difficulty.
During Hospitalization:
His sleeping pattern was greatly altered due to his condition.
His level of consciousness was reduced. As a result of the
brain injury, he easily falls asleep.
Cognitive-Perceptual Pattern

Before Hospitalization:
He is a college undergraduate (B.S. in Chemical Engineering)
He speaks Ilokano, Tagalog, English
He is fully oriented to time and persons around her.
He is able to answer questions immediately.
He can hear soft whisper, identify things/objects, smell and
taste foods and able to respond to stimuli.
During Hospitalization:
Since his brain was injured he experiences the signs of
contusion: dizziness, increased size of one pupil (4mm),
sudden weakness in an arm or leg (left), have memory loss.
Self-Perception-Self- Concept Pattern
Before Hospitalization:
The mother views her child as a patient individual coupled
with humble and intelligent acts.
He has strong determination and a man with great courage.
He fears of losing someone. The mother said that he says,
Mas maganda na yung ako ang maunang mamatay.
During Hospitalization:
The mother knew that his child is not in good condition.
She worries about her childs condition however she further
said that the patient doesnt want his family to be seen
worried at someone or something.
Role Relationship Pattern
Before Hospitalization:
He is a loving brother.
He is in good terms with the family members.
He loves to mingle with different kind of people.
When conflict arises, he wants to resolve it immediately with
the help of her mother.
They have a nuclear family.
He is the eldest child to his parents and also the eldest
grandchild.
Have 2 younger siblings that he loves very much.
During Hospitalization:
The mother knew that he can no longer attend to his family
due to present condition.
The family is in rotation to be with her as her guide. Her
mother is very worried with his condition.

Sexuality-Reproductive Pattern

He has no complications in her Reproductive System

Circumcision at age 11
The patient is a teenager and single.

Coping Stress Pattern

He is in stressed whenever problems arises.

In times of problems, he talks about it with his family and
finds ways and means to solve it.
He copes with her condition by taking enough rest and sleep
and following the doctors order.
The patient is a student. He enjoys listening to music. This is
his way of relaxing. He also eats his meals and makes sure
that he gets enough sleep and rest.

Value-Belief Pattern

He is a Roman Catholic.
He and his family attend mass.
They also have some superstitious beliefs like not sweeping at
night and many more.
The mother strongly believes in miracles and power of God.
She prays always and thank God for the blessings He is doing
for the everyday improvement of his childs condition.
The Lord is their source of strength.

Physical Assessment
Date Assessed: September 14, 2007
Time Assessed: 8:30 AM
Initial Vital Signs:
Temperature: 36.90C
Pulse Rate: 89 bpm
Respiratory Rate: 28 cpm
Blood Pressure: 130/80 mmHg
General Appearance:
The patient is awake, lying on bed with an IVF at the left arm.
With NGT at the left nares
With condom catheter connected to urine bag
The patient is somewhat stupurous.
The patient cannot follow instructions and commands easily due
to present condition.
AREA
ASSESSED
SKIN
Color

TECHNIQUE
S USED

NORMAL
FINDINGS

ACTUAL
FINDINGS

ANALYSI
S

Inspection

Tan

Texture
Turgor

Palpation
Palpation

Due to
accident
Normal
Normal

Hair
Distribution
Temperature

Inspection

Moisture

Palpation

Smooth, soft
Skin snaps
back
immediately
when
pinched
Evenly
distributed
Warm to
touch
Dry, skin
folds are
normally
moist

Tan, with
bruises
Smooth, soft
Skin snaps
back
immediately
when
pinched
Evenly
distributed
Warm to
touch
Dry, skin
folds are
normally
moist

Pink and
Clean
Smooth
Convex
curvature
Firm
2-3 seconds

Pink and
Clean
Smooth
Convex
curvature
Firm
2-3 seconds

Normal

Black (varies)
Evenly
distributed
Neither
excessively
dry nor oily
Silky,
resilient

Black
Evenly
distributed
Neither
excessively
dry nor oily
Silky,
resilient

Normal
Normal

NAILS
Color of
nailbed
Texture
Shape

Palpation

Inspection
Palpation
Inspection

Nail Base
Capillary
Refill time
HAIR
Color
Distribution

Inspection
Blanch Test

Moisture

Inspection

Texture

Inspection

HEAD

Inspection
Inspection

Normal
Normal
Normal

Normal
Normal
Normal
Normal

Normal
Normal

Scalp
Symmetry
Skull Size

Inspection

Symmetrical

Symmetrical

Normal

Inspection
Inspection
and
Palpation
Palpation

Normocephal
ic
Round

Normal

Shape

Normocephal
ic
Round
Absence of
nodules and
masses

Absence of
nodules and
masses

Normal

Inspection
Inspection

Symmetrical
Symmetrical

Symmetrical
Symmetrical

Normal
Normal

Inspection

Tan

Tan

Normal

Inspection

Symmetricall
y aligned,
equal
movement
Slightly
curved
upward
Smooth, tan,
do not cover
pupil as
sclera, close
symmetricall
y

Symmetricall
y aligned,
equal
movement
Slightly
curved
upward
Smooth, tan,
do not cover
pupil as
sclera, close
symmetricall
y

Normal

Due to
present
condition,
CNS
affected

Nodules/
Masses
FACE
Symmetry
Facial
Movement
Skin color
EYES
Eyebrows

Eyelashes

Inspection

Eyelids

Inspection

Ability to
blink

Inspection

Blinks
voluntarily
and
bilaterally

Frequency of
blinking

Inspection

20 blinks per
minute

Steady eyes
sometimes
but it blinks
voluntarily
and
bilaterally
13 blinks per
minute

Ocular
movement

Inspection

Eye moves
freely

Eye do not
move freely

Position

Inspection

Size
Texture

Inspection
Palpation

Drawn from
lateral angle
Medium
Mobile, firm
and non
tender

Drawn from
lateral angle
Medium
Mobile, firm
and non
tender

Conjunctiva
Color

Inspection

Transparent
with light

Transparent
with light

Normal

Normal
Normal

Due to
present
condition,
CNS
affected
Due to
present
condition,
CNS
affected
Normal
Normal
Normal

Normal

color
Shiny and
smooth
No lesions

color
Shiny and
smooth
No lesions

Inspection
Inspection

Clear
Shiny,
smooth,
transparent

Clear
Shiny,
smooth,
transparent

Normal
Normal

Pupils
Color
Reaction to
light

Inspection
Inspection

Inspection
Inspection

Symmetry
Visual Acuity

Inspection
Inspection

Black
Pupils
Equally
Round and
React to
Light
Accommodat
ion (PERRLA)
Equal
Round and
constrict
briskly
Equal in size
-not able to
assess due
to his
condition -

Normal
Normal

Size
Shape

Black
Pupils
Equally
Round and
React to
Light
Accommodat
ion (PERRLA)
Equal
Round and
constrict
briskly
Equal in size
Able to real
news print

Visual Fields

Inspection

-not able to
assess due
to his
condition -

Ocular

Inspection

When looking
straight
ahead, client
can see
objects in
periphery
Eyes move
freely

Eyes do not
move freely

Due to
present
condition,
CNS
affected

Symmetrical,
smooth and
tan
Reddish to
Pinkish

Symmetrical,
smooth and
tan
Reddish to
Pinkish

Normal

Oval,
symmetrical
No discharge

Oval,
symmetrical
No discharge

Normal

Texture

Inspection

Presence of
lesions
Lacrimal
Apparatus

Inspection

Cornea
Clarity
Texture

NOSE
Symmetry,
shape, size
and color
Mucosa color
Nasal
Septum
Nares
Nasal
discharge

Inspection
Inspection

Inspection
Inspection

Normal
Normal

Normal
Normal
Normal
-not able
to assess
due to his
condition
-not able
to assess
due to his
condition
-

Normal

Normal

Sinuses
MOUTH

Inspection

Not tender

Not tender

Normal

Lips
Color

Inspection
Inspection
Palpation

Moisture

Palpation

Pinkish to
slightly
brown
Symmetrical
Soft, moist,
smooth
Soft and
moist

Normal

Symmetry
Texture

Pinkish to
slightly
brown
Symmetrical
Soft, moist,
smooth
Soft and
moist

Inspection
Palpation

Pinkish
moist

Pinkish
moist

Normal
Normal

Inspection

Glistening
pink
Soft
moist

Normal

Gums
Color
Moisture
Buccal
Mucosa
Color

Normal
Normal
Normal

Texture
Moisture
Tongue
Color
Size
Symmetry
Mobility

Palpation
Palpation

Glistening
pink
Soft
moist

Inspection
Inspection
Inspection
Inspection

Pinkish
Medium
Symmetrical
Moves freely

Pinkish
Medium
Symmetrical
Moves freely

Normal
Normal
Normal
Normal

Uvula
Location

Inspection

At the
midline
Symmetrical

At the
midline
Symmetrical

Normal

Inspection
Inspection

Pinkish
No
discharges

Pinkish
No
discharges

Normal
Normal

Inspection

Ivory/yellowis
h
32

Yellowish

normal

30

Due to
tooth
decay
(tooth
extraction
)

HeadCentered
Do not freely
move

Normal

Symmetry
Tonsils
Color
Discharges
Teeth
Color
Number of
teeth

Inspection

Inspection

NECK
Position

Inspection

Movement

Inspection

HeadCentered
Moves freely

Range of
Motion

Inspection

Full range

Not in full
range

Consistency

Inspection

No
Enlargement

No
Enlargement

Normal
Normal

Normal

Due to
present
condition
Due to
present
condition
Normal

HEART
Heart rate
Heart sounds

Auscultation
Auscultation

100-120bpm
Clear,
without
crackles

89 bpm
Crackling
sound

Lung Field

Auscultation

Resonant

With crackles

Inspection

Symmetrical

Symmetrical

Normal

Inspection

Normally 1220 cpm

Spine
vertically
aligned

16 cpm

Normal

Spine
vertically
aligned

Normal

Breathing is
automatic
and
effortless,
regular and
even and
produces no
noise.
Bronchovesicular

Breathing is
with effort,
produces
noise when
breathing.

Due to
retained
secretions
in the
lungs

Wheezes

Due to air
passing to
a
constricte
d
bronchus
as a result
of
secretions
.

Flat
Smooth
Audible; soft
gurgling
sound occur
irregularly
and rages
from 5-30
minutes

Flat
Smooth
Hypoactivedecreased
motility

Normal
Normal
Due to
constipati
on

THORAX
AND LUNGS
Posterior
Thorax
Symmetry
Respiratory
rate
Spinal
alignment
Anterior
Thorax
Breathing
pattern

Lung/ breath
sounds

ABDOMEN
Contour
Texture
Frequency
and
character

UPPER
EXTREMITY

Inspection

Auscultation

Auscultation

Inspection
Palpation
Auscultation

Normal
Due to
the
presence
of phlegm
and
increased
mucus
productio
n
Due to
secretions

Skin color

Inspection

Tan

Size (arms)
Symmetry
Hair
distribution
LOWER
EXTREMITY
Skin color

Inspection
Inspection
Inspection

Equal
Symmetrical
Evenly
distributed

Inspection

Tan

Size (legs)
Symmetry
Hair
distribution
NEUROLOGI
C
Level of
consciousnes
s

Inspection
Inspection
Inspection

Equal
Symmetrical
Evenly
distributed

Interview

Can follow
instructions
and
commands

Behavior and
appearance

Interview

Makes eye
contact with
the examiner

Mood

Interview

Expresses
feelings
which
correspond
to situation

Do not
expresses
feelings
which
correspond
to situation

Interview

Clear and
strong

Not clear and

strong

Tone

Interview

Fluent and
articulated

Not fluent
and
articulated

Manner and
speech

Interview

Can give
appropriate
answers to
questions

Cannot give
answers to
questions

Interview

Oriented with
time

Not oriented
with time

Mannerism
s and
actions
Language
Voice
inflection

Mental
Status
Orientation

Tan with
bruises
Equal
Symmetrical
Evenly
distributed

Due to
accident
Normal
Normal
Normal

Tan with
bruises
Equal
Symmetrical
Evenly
distributed

Due to
accident
Normal
Normal
Normal

Cannot
follow
instructions
and
commands
Do not make
eye contact
with the
examiner

Due to
present
condition,
CNS
affected
Due to
present
condition,
CNS
affected
Due to
present
condition,
CNS
affected

Due to
present
condition,
CNS
affected
Due to
present
condition,
CNS
affected
Due to
present
condition,
CNS
affected
Due to
present
condition,
CNS
affected

Time
Recall recent
and remote
memory

Judgments
and thoughts

Interview

Recall events
readily,
immediate
recall of
remote
information

Interview

Can make
logical
decisions

Cannot recall
events
readily,
immediate
recall of
remote
information
Cannot make
logical
decisions

Due to
present
condition,
CNS
affected
Due to
present
condition,
CNS
affected

Pathophysiology of Cerebrovascular Accident

Predisposing
Factors

Etiology

age
sex
history of
hypertension,
atherosclerosis,
cardiac conditions

Cerebral
Hemorrhage

Precipitating
Factors
lifestyle
environment

Occlusion of major vessel by

embolism

Other causes
of ischemia

Cerebral
infarction

Decreased flow of blood to brain

Hypoxia

Cerebral edema

Vascular congestion

Compression of tissue

Impaired function

Anterior cerebral artery

Middle cerebral artery

Posterior cerebral artery

Drug Study
Anterior cerebral artery
Middle cerebral artery
Brand Name: Dilantin
Generic Name: Phenytoin
Classification: Anticonvulsant
Dosage
Frequency: DilantinArm
125/
5mL BID/ NGT
Confusion
paralysis
Route:
per NGT
Impaired
thought
process
Hemianopia

Posterior cerebral artery

Hemiparesis
Ataxia
Contralateral paralysis/paresis
Aphasia
Visual problems
Indications:
Urinary
incontinence
Agnosia
Dysphasia
Tonic-clonic
& psychomotor
seizures
Sensory
deficits
Perception
deficits
dysphonia
prevention & treatment of seizures occurring during or following
neurosurgery
Mode of Action:
Phenytoin is eliminated mainly through para- hydroxylation by a
cytochrome
system.
The metabolic
pathway isblood
subject
ReturnP450
of normal
perfusion
Continued inadequate
flow to
saturable kinetics in overdose, allowing accumulation of free
phenytoin. Even at therapeutic doses, accumulation of free phenytoin
is possible in: hypoalbuminaemia, chronic renal failure, hepatic
dysfunction,
hereditary
insufficient para-hydroxylation,
and inhibition
Decreased
edema
Further tissue compression
of phenytoin metabolism by other drugs.
Phenytoin binds to specific site on voltage-dependent sodium
channels and is thought to exert its anticonvulsant effect by
suppressing
the sustained
of neurons
Improved
functionrepetitive firing
Cerebral
death by inhibiting
sodium flux through these voltage dependent channels. Phenytoin
stabilises membranes, protecting the sodium pump in the brain and in
the heart. It limits the development of maximal convulsive activity and
reduces the spread of convulsive activity from a discharging focus
without influencing the focus itself. Phenytoin has antiarrhythmic
properties similar to those of quinidine or procainamide. Although
phenytoin has minimal effect on the electrical excitability of cardiac
muscle, it decreases the force of contraction, depresses pacemaker
action and improves atrioventricular conduction. It also prolongs the
effective refractory period relative to the action potential duration.
Contraindications:
History of hypersensitivity to hydantoins.
Special Precautions:
Severe myocardial insufficiency
hepatic impairment
porphyria
Avoid abrupt withdrawal
Adverse Drug Reactions
GI disturbances:
ataxia
slurred speech
diplopia
nystagmus
mental confusion w/ headache, dizziness, gingival hyperplasia,
hirsutism, hyperglycemia, osteomalacia.
Nursing Responsibilities:

Assess drug level: toxic level 30-50ug/ml

Assess mental status: mood, sensorium, memory

Assess for blood dyscrasias: fever, sore throat, bruising, rash,

jaundice, epistaxis

Assess seizure activity including type, location, duration and

character; provide seizure precaution

Assess renal studies: urinalysis, BUN, urine creatinine

Monitor blood studies: RBC, Hct, Hgb; check thyroid function test,
serum calcium

Monitor hepatic studies: ALT (SGPT), AST (SGOT), bilirubin,

creatinine

Assess for signs of physical withdrawal if medication suddenly

discontinued

Assess eye problems

Assess allergic reaction

Should be taken with food (When administering to patients on

nasogastric or other enteral feeds, be consistent throughout
therapy in relation to feed times. Do not switch dosage forms/
brands without prior consideration.)

Brand Name: Omepron

Generic Name: Omeprazole
Classification: Antiulcerant, Proton pump inhibitor
Drug Frequency: Omeprazole (Omepron) 20mg/cap 1 cap OD/ NGT
Route: per NGT
Indications:
Active duodenal ulcer & GERD w/ erosive esophagitis, Gastric
ulcer, Symptomatic GERD w/o esophageal lesions, Maintenance of
healing of erosive esophagitis, Pathological hypersecretory conditions
eg Zollinger-Ellison syndrome, H. pylori eradication in peptic ulcer
disease
Mode of Action:
Proton pump inhibitors act by irreversibly blocking the
hydrogen/potassium adenosine triphosphatase enzyme system (the
H+/K+ ATPase, or more commonly just gastric proton pump) of the
gastric parietal cell. The proton pump is the terminal stage in gastric
acid secretion, being directly responsible for secreting H+ ions into the
gastric lumen, making it an ideal target for inhibiting acid secretion.
Targeting the terminal-step in acid production, as well as the
irreversible nature of the inhibition, result in a class of drugs that are

significantly more effective than H2 antagonists and reduce gastric

acid secretion by up to 99%.
The proton pump inhibitors are given in an inactive form. The
inactive form is neutrally charged (lipophilic) and readily crosses cell
membranes into intracellular compartments (like the parietal cell
canaliculus) that have acidic environments. In an acid environment,
the inactive drug is protonated and rearranges into its active form. As
described above, the active form will covalently and irreversibly bind to
the gastric proton pump, deactivating it.
Special Precaution:
Symptomatic response to therapy does not rule out presence of
gastric malignancy. Pregnancy & lactation.
Adverse Drug Reactions:
Constipation, diarrhea, flatulence, nausea, vomiting & acid
regurgitation. Abdominal pain, asthenia, headache, dizziness, rash.
Nursing Responsibilities:

Document indicationms for therapy, triggers, frequency and

characteristics of symptoms

Record abdominal assessment, radiographic/ endoscopic findings

and H. pylori results

Monitor U/A, CBC, LFTs; note any hepatic dysfunction

Determine if pregnant

Should be taken with food (Administer before a meal.).

Generic Name: Lactulose

Classification: Laxative
Drug Frequency: Lactulose 30cc/NGT BID (hold for bowel movement
2x a day
Route: per NGT
Indication:
Constipation; bedridden and geriatric patients; surgical
procedures; painful rectal and anal conditions; laxative dependence;
barium x-ray investigations; drug induced constipation.
Mode of Action:
Lactulose may promote the growth of favorable bacterial
populations, such as bifidobacteria, in the colon.
Lactulose may aid in lowering serum triglycerides in some.
Decreased hepatocyte de novo synthesis of triglycerides is one
hypothetical possibility. Lactulose may also lower total cholesterol and
LDL-cholesterol levels in some.

Lactulose may delay gastric emptying and/or shorten smallintestinal tract transit time. This may be via the short-chain fatty acids
produced from lactulose in the colon.
Lactulose may bind/sequester such minerals as calcium and
magnesium in the small intestine. The short-chain fatty acids formed
from the bacterial fermentation of lactulose may facilitate the colonic
absorption of calcium and, possibly, also magnesium ions. This could
be beneficial in preventing osteoporosis and osteopenia.
Contraindication:
Galactosaemia, bowel obstruction
Special Precautions:
Diabetes, lactose intolerance, pregnancy & lactation.
Adverse Reaction:
Flatulence, Diarrhea
Nursing Responsibilities:

Monitor glucose levels in diabetic

Monitor blood, urine, electrolytes if used often by patient; may
cause diarrhea, hypokalemia, hyponatremia; check I and O ratio
to identify fluid loss
Assess cramping, rectal bleeding, nausea, vomiting. If these
symptoms occur, drug should be discontinued; identify cause of
constipation; identify whether fluids or exercise is missing from
lifestyle
Monitor blood ammonia level (30-70mg/100ml); monitor for
clearing confusion, lethargy, restlessness, irritability
May be taken with or without food (May be administered w/
meals to reduce GI discomfort.).

Brand Name: Somazine

Generic Name: Citicoline (CDP-choline)
Classification: CNS stimulant
Dosage Frequency: Somazine 500mg/cap/ NGT
Route: per NGT
Indication:
CVA in acute and recovery phase, symptoms and signs of
cerebral insufficiency e.g. dizziness, memory loss, poor concentration,
disorientation, recent cranial trauma.
Mode of Action:
Since the action of CDP-choline either as a pharmaceutical or
nutraceutical agent has yet to be clarified, discussion of its mechanism
of action is speculative. However, much is known about the
biochemistry of endogenous CDP-choline. CDP-choline is an
intermediate metabolite in the major pathway for the synthesis of the
membrane phospholipid, phosphatidylcholine. Phosphatidylcholine is
crucial for the maintenance of cell-membrane fluidity and cellular
integrity. CDP-choline, hypothetically, may aid in cell-membrane repair,

particularly neuronal cell membranes that have been damaged by

trauma, ischemic events, toxins, infections or during the course of
aging.
CDP-choline is also a delivery form of choline and cytidine.
Choline is a precursor of acetylcholine and betaine. Acetylcholine is a
neurotransmitter whose deficiency in certain regions of the brain is
believed to be an etiological factor in certain dementia syndromes,
including Alzheimer's disease.
Contraindication:
Parasympathetic hypertonia
Adverse Reaction:
GI disorders
Nursing Responsibilities:
Note indications for therapy, onset and characteristics of illness
May be taken with or without food (Take w/ or between meals.).
Generic Name: Levofloxacin
Classification: Quinolone
Dosage Frequency: Levofloxacin 500mg/tab 1 tab OD
Route: per NGT
Indication:
Acute bacterial exacerbation of chronic bronchitis. Community
acquired pneumonia. Acute maxillary sinusitis. Uncomplicated skin and
soft tissue infections. Complicated UTI. Acute nephronepritis.
Pneumonia. Complicated UTI including pyelonephritis. Infections where
bacteremia/ septicemia is present.
Mode of Action:
Levofloxacin reaches its peak levels in skin tissues and in blister
fluid of healthy subjects at approximately 3 hours after dosing. The
skin tissue biopsy to plasma AUC ratio is approximately 2 and the
blister fluid to plasma
Levofloxacin is stereochemically stable in plasma and urine and
does not invert metabolically to its enantiomer, D-ofloxacin.
Levofloxacin undergoes limited metabolism in humans and is primarily
excreted as unchanged drug in the urine.
Contraindication:
Hypersensitivity to quinolones, epilepsy, history of tendon
disorders related to fluoroquinolone therapy, pregnancy, lactation.
Special Precautions
Child & adolescents <18 yrs, patients w/ known or suspected
CNS disorders, predisposed to seizures or low seizure threshold.
Pregnancy & lactation.
Adverse Drug Reactions
Ascites, allergic reaction, disorders of the GI, liver & biliary
system, resp system, CV system. Heart rate & rhythm, platelet,

bleeding & clotting, white cell & reticuloendothelial, vascular,

peripheral & CNS disorders, vision, hearing & vestibular disorders.
Anemia, parosmia, psychiatric disorders, metabolic & nutritional
disorders, musculo-skeletal system disorders, skin & appendage
disorders, urinary system & resistance mechanism disorders,
neoplasms.
Nursing Responsibilities:
Note indications fro therapy, onset and characteristics of illness
Assess for any seizure history or CNS disorders
Obtain baseline cultures, CBC, liver and renal function studies.
Follow guidelines for reduced dosage with renal impairment
May be taken with or without food (Ensure adequate fluid
intake.).
Generic Name: Mannitol
Classification: Osmotic Diuretic
Dosage Frequency: Mannitol 50cc/IV every 8 hours
Route: parenteral
Indication:
Diuretic to prevent or treat the oliguric phase of acute renal
failure before irreversible renal failure occurs. Decrease ICP and
cerebral edema by decreasing brain mass. Decrease elevated
intraocular pressure when the pressure cannot be lowered by other
means. To promote urinary excretion of toxic substances. As a urinary
irrigant to prevent hemolysis and hemoglobin build-up during
transurethral prostatic resection or other transurethral surgical
procedures.
Mode of Action:
Increases the osmolarity of the glomerular filtrate, which
decreases the reabsorption of water and increases excretion of sodium
and chloride. It also increases the osmolarity of the plasma, which
causes enhanced flow of water from tissues into the interstitial fluid
and plasma. Thus, cerebral edema, increased ICP and CSF volume and
pressure are decreased.
Contraindications:
Anuria, pulmonary edema,
severe dehydration,
active
intracranial bleeding except during craniotomy, progressive heart
failure or pulmonary congestion after mannitol therapy, progressive
renal damage following mannitol therapy.
Adverse Reaction:
Fluid and electrolyte imbalance, acidosis, loss of electrolytes,
dehydration. Nausea, vomiting, dry mouth, thirst, diarrhea. Edema,
hypotension, increase in heart rate, angina-like chest pain, CHF,
thromboplebitis. Dizziness, headache, blurred vision, seizures.
Pulmonary congestion, marked diuresis, rhinitis, chills, fever, urticaria,
pain in arms, skin necrosis.
Nursing Responsibilities:

Assess neurologic status

Assess for visual changes or eye discomfort or pain
Assess patient for tinnitus, hearing loss, ear pain; periodic testing
of hearing is needed when high doses of this drug are given by IV
route
Monitor manifestations of hyponatremia and hypokalemia
Assess fluid volume status
Assess for dehydration
Monitor electrolytes
Assess blood pressure before and during therapy
Monitor for rebound intracranial pressure

Brand Name: Centrum

Generic Name: Multivitamins
Classification: Multivitamins/with Minerals
Dosage Frequency: Multivitamins (Centrum) 1 tab OD/ NGT
Route: per NGT
Indications
Complete multivitamin & mineral formula.
Nursing Responsibilities:

May be administered with or without food (May be taken w/

meals for better absorption or if GI discomfort occurs.).

Learning Feedback Diary

Area: Saint Paul Hospital (Floor 2)
Date: September 13-14, 2007
Time: 7 am 3pm
Objectives:
At the end of the shift I will be able to:

Build rapport with the patient

Provide a complete bedside care to the patient
Administer medicines properly
Apply the knowledge and skills learned in real life situation
apply therapeutic communications learned
Appreciate the importance of hospital duty experience in
providing better care for the patients
render a Paulinian nursing service

Learnings/Insights:
For this last rotation, I was so anxious and at the same time very
excited for I am again to render a Paulinian nursing care to a certain
patient. I am anxious for the reason that I thought I am already late for
I also woke up late. And of course I also thought that Maam Gladys is
already in the school checking the attendance. And Im afraid these
thoughts would happen because I dont want to embarrass myself to
her. I dont want her to remember me of this kind of student. Many
thoughts really magnified me; one of it also is that she is inconsiderate
and a sort of a cannot be reached teacher. So as I rode in the tricycle
going to school, I am really nervous. All I thought, this would be a bad
day for me for the last rotation because if ever, it would be a
remarkable one because for the first time I was late. When I arrived in
school, it was the opposite of what I thought. Maam Gladys was not
yet around so the day was not yet messed up. It was yet a beautiful
morning of my last rotation this first semester.
As usual, the daily routine of going to duty was done and we
went to St. Paul Hospital for our duty.
As we were in back of Maam Gladys, I was somewhat assessing
of who really she was. But I cant guess the right one and I dont want
to stand on the saying that First impression lasts.
I was amazed too with the new adjacent Sacred Heart in which a
Student Lounge was provided for us. So as we walk through it, I am
imagining walking an U.S. hospital (as what I am callinghehe).
However, there was a great deal of the aircon because someone turned
it on in which the SPH administrator made it really a big deal for them.
This also caused the delay of our duty.
After the incident, our duty continued. So for this time, we are in
pairs. I was paired with Ms. Sheene Krissel Rey and the patient we
handled had a case of Dengue. I was not able to like this one because
the things to be done are somewhat boring and I just can learn little of

this case. But as I went through it, I learned to love doing TSB to the
patient.
On the next day, we were on our way to individual but,
unfortunately, I was paired again to Ms. Myera Angelica Ancheta. At
first, I hated it again. But when I saw the patient, my presumptions
were wrong that I could handle the patient my own. So it was really
intended for two. As I saw the patient, I am very happy for I had
thought of the learnings I will have for today. And luckily, I did it a
toxic patient for a learning like NGT feeding, right preparations and
administration of medications, draining the urine.
It was really a wonderful duty day for me. I had gained lots of
skills but also of knowledge. It was an opportunity for me to handle
such patient like that. It was a door for me to appreciate more the high
vocation of my chosen career.

Learning Feedback Diary

Area: Saint Paul Hospital (Floor 2)
Date: September 20-21, 2007
Time: 7 am 3pm
Objectives:
At the end of the shift I will be able to:

Build rapport with the patient

Provide a complete bedside care to the patient
Administer medicines properly
Apply the knowledge and skills learned in real life situation
apply therapeutic communications learned
Appreciate the importance of hospital duty experience in
providing better care for the patients
render a Paulinian nursing service

Learnings/Insights:
This time, Myera and I had cared for the same patient. So it was
not anymore a hindrance for us to establish rapport with the family. We
now knew the things to be done so Maam Gladys had entrusted us for
those things but of course with her supervision. The patient we really
handled is the best duty day I had for I really had the chance to care
for such a toxic one. It was then a dream a come true. (hehehe
because I am looking forward to a patient that can teach me the skills I
want to perform). Since this was the last we handled the patient;
though I am not related with him, minutes before the duty ended, I
grasp his hand, and I prayed for him and his fast recovery and of
course to his family.
The last day of duty, I handled a patient with a Diabetes Mellitus,
I was again bored and I felt sleepy then for I am not doing something
except for assisting her with the toileting, raising the siderails and
talking with the SO. I was also a little bit irritated with the patient for
she was like a kid. She is somewhat naughty. But of course, as a nurse,
we are there to render service. So I just did my part as her student
nurse. I had given her the Paulinian nursing care.
From the days I am under the care of Maam Gladys, I have also
known her. She proved me wrong of who really she is. Aside from being
beautiful outside, she is also beautiful inside. She really is a beautiful
creation of God. She had shared us what she knows. And I was able to
appreciate that she doesnt not just correct our mistakes but also
lecture us. I really enjoyed being with her because she is easy to be
with and also fun to be with. She knows how to go with the flow of her
student.
This last duty day, it was a goal met for me. Caring for people
was just a dream when I was a little girl, but now, I was able to do it. I
love being a nurse and I love caring for people. I am looking forward for
more duty days to come so I would be able to render my service to
others and would practice the knowledge and skills learned so I would

become not just a better nurse someday but the best nurse imbued
with the attitude carrying a Paulinian nursing service.

Learning Feedback Diary

Name: Myera Angelica G. Ancheta
Date: September 13-14, 2007
Time: 7AM-3PM
Venue: Sph- F2
Clinical Instructor: Ms. Gladys Pagunuran, RN
Learning Objectives
To be acquainted with the procedures in the area
To develop rapport with my patient
To apply the knowledge and skills learned from school
To gain new experiences that are essential to improve my
performance
To render a good nursing care

For our last rotation for the semester, we had our duty at St. Paul
Hospital (F2). Being familiar with the place, I was more relaxed as
compared to my previous rotations. Im somewhat acquainted with the
procedures done as well as with the policies in the hospital.
Our duty days started with our usual routine which includes the
checking of attendance followed by a prayer done in front of the grotto.
And being scheduled in an AM shift, I had to wake up early in the
morning for me to be in school on time in order to participate in the
said activities.
When we had reached the hospital our clinical instructor endorsed to
us our respective patients- we were then in pairs. Upon receiving our
patient who was then suffering from CVA, I was challenged because Im
aware that he will need a good nursing care. Moreover, I knew that
such situation will give me a lot of new experiences that will enhance
my knowledge and develop my skills. And I was right! I had learned a
lot. I became familiar with some of the procedures done for this case
and was given the chance to perform them. I was able put into practice
some of the skills taught to us in school such as NGT feeding,
preparation and administration of medications and charting.
Therefore, I can conclude that this experience had given me the
opportunity not only to apply my knowledge and skills but also to
develop new ones as well. I came to appreciate my role as a nursing
student in providing care to those who are in need of it.

Learning Feedback Diary

Name: Myera Angelica G. Ancheta
Date: September 13-14, 2007
Time: 7AM-3PM
Venue: Sph- F2
Clinical Instructor: Ms. Gladys Pagunuran, RN
Learning Objectives:
To apply the knowledge and skills learned from school
To apply an effective therapeutic communication technique
To improve my skills and gain more confidence
To render a good nursing care
For the third day of our rotation, my partner and I handled the same
patient. Thus, we had already develop rapport with our patient and his
SO. Moreover, I became more confident about my actions and was able
to perform my tasks better.
And on our last day, I was assigned as the team leader of the group.
Again, this is a nice experience for me. It taught me a lot of new things.
I was given the chance to render a good nursing care to diffirent
patients. I came to meet different types of people having different
health needs and was given the opportunity to take good care of them
and to assist them with most of their needs.
Thus, I can say that my duty was indeed filled with great experiences
that are essential in order for me to improve my performance. It
provided me with a great training ground and had helped me develop
my confidence. Through it, I came to appreciate the importance of
establishing a good rapport with our patients. Gaining their trust will
enable us to render service effectively.
The semester is almost over. And as a beginner, I admit that I had a
rough start. However, I am hopeful that as I go through this training I
will eventually master the necessary knowledge and skills in order for
me to be an effective health care provider.