Chf

I. Demographic Data

Client’s Name:

Manang

Sex:

Female

Age:

71 years old

Birthdate:

September 18, 1937

Birthplace:

Liliw, Laguna

Status:

Married

Nationality:

Filipino

Religion:

Roman Catholic

Address:

Liliw, Laguna

Educational Background:

Elementary Graduate

Occupation:

None

Hospital:

Community General

Hospital Date of Admission:

June 29, 2009

Final diagnosis:

CVA, Subarachnoid

Hemorrhage

II. Sources and Reliability of Information Upon interview and history taking, data were gathered from the patient’s laboratory

relatives. results,

All

the

diagnostic

significant

information

procedures,

regarding

medication

orders, 1

physical findings, and other pertinent records were acquired from the patient’s chart. The patient was observed and assessed during physical assessment to obtain relevant data that is vital in identifying actual and potential problems.

III. Reason for Seeking Care Manang was brought to Community General Hospital on June 29, 2009 at 8:00 pm after being referred to by Nagcarlan Hospital. She was found unconscious by her granddaughter at 5:30 pm. She was immediately rushed to the hospital by her son and nephew. IV. History of Present Illness Three hours prior to admission, Manang had been feeling dizzy while she was watching television. This dizziness eventually progressed to loss of consciousness. V. Past Medical History According to the relatives, Manang has had hypertension since she was 40 years old. She has been taking her maintenance medications religiously until a month ago when they noticed that she was purposely skipping taking them. The relatives could not recall what her meds are. They also said that it was the second time the patient experienced stroke. The first time was in 2001 while she was in ballroom dancing.

2

VI. Family History

Patient’s Paternal Grandpa; unrecalleddeceased

Patient’s Paternal Grandma; unrecalleddeceased

Patient’s Maternal Grandpa; unrecalleddeceased

Patient’sFather deceased

Patient’s husband 71 y/o

Patient’s Maternal Grandma; unrecalleddeceased

Patient’sMother deceased

Patient Manang 71 y/o

Brother Deceased at age 67 (HPN, DM,,renal disorder)

Legend:

Patient: CVA HEMORRHAGIC (Subarachnoid) Deceased

Female:

3

Male: Deceased

Male: Hypertensive

According to the family history, Manang’s parents are both deceased including her grandparents from both sides due to reasons unrecalled by her relatives. She has one younger brother who died at the age of 67 a month before her hospitalization because of complications brought about by diabetes. Manang’s husband is hypertensive also. The family history shows hypertension in the family since she and her brother got it.

VII. Functional Assessment A. Health Perception and Maintenance Manang regularly visited hospital for check-ups. As mentioned, she sticks to her pharmacologic regimen in order to take good care of her health. But when her brother passed away a month ago, she started to skip her medications and became stressed. B. Activities/ Exercise Pattern Manang does not engage into a regular exercise. But her relatives mentioned that she does household chores because she could not stand dirty things. These chores made her busy at home and serve as her own exercise. They said that she doesn’t stop until all the furniture’s and dishes are clean. C. Sleep/ Rest Period When asked about her sleeping pattern, the relatives said that she’s not getting enough sleep. She only has about three hours of sleep a 4

day. Because of being awake even late at the night, she tried to find time to rest at daytime. She managed to take a nap.

D. Nutrition and Elimination Manang is fond of eating vegetables, fruits, and meat. Her relatives told us that she loves coffee. According to her relatives, her bowel movement is not regular. She did it once in three days before she was hospitalized. E. Interpersonal Relationship The life of Manang centers on her husband and six off springs (all of them has their own family). Her relatives mentioned they regularly visit Manang to keep her company because she completely dotes on her grandchildren. They also shared with us that Manang has a good relationship with the neighbors. F. Sexuality and Reproductive Manang is already on her menopausal years. According to the relatives, she and her husband get along pretty well. According to Erik Erikson’s theory, she’s now on her “Integrity versus despair” stage. G. Coping and Stress Management/ Tolerance Pattern Manang has an unwavering faith in the Lord and she attended mass regularly with her husband. Whenever problems come their way,

5

she just prayed and believed everything will be okay for as long as God is with you. She and her family stay together to solve whatever hardships arise. But lately, things are not getting too smooth for Manang. Her relatives stressed that Manang considered the death of her brother a blow to her for she is very fond and close to him. Even if they tried to cheer her up, the loneliness stayed with her. H. Personal Habits Manang stayed at home and spent her leisure watching television. She used to engage in ballroom dancing but since her first stroke in 2001, she stopped doing this and just concentrated on making their home clean. When she gets bored, she sometimes goes to one of her neighbors to chat. I. Environmental Hazards The house of Manang is near the highway where all forms of transportation pass. Her relatives say that the noise coming from the vehicles are loud but it’s bearable. They mentioned that when it rains heavily, it does not flood in their area. VIII. Review of Systems System General Appearance

1st day July 9, 2009 • Expressive aphasia • Conscious • Afebrile • With protruded tongue • Capillary refill

2nd day July 10, 2009 • Expressive aphasia • Conscious • Afebrile • With protruded tongue • Poor eye 6

• • • •

•

• • • HEENT

• • • • • •

Cardiovascular

• • •

Integumentary

• •

Gastro intestinal tract

• • •

of 2 – 3 seconds Poor eye contact Psychomotor decreased Pale nail bed Soft palate fails to rise in paralysis on cranial nerve X Impaired and limited coordination by weakness Decreased muscle strength Uses incomprehensib le sounds noted drooling of saliva Slight loss of hearing With hair thinning With NGT @ the right nostril Pupil 2mm,sluggishly reactive to light Anicteric sclera Pink palpebral conjunctiva BP 130/80 mmhg PR 68 bpm With full equal pulses Slightly flaky skin Pale in appearance Slightly dry lips Pale nail bed Flabby abdomen

• • •

• • •

• • • • •

• •

• • • • •

contact Psychomotor decreased Pale nail bed Impaired and limited coordination by weakness Decreased muscle strength Uses incomprehensib le sounds Noted drooling of saliva

Slight loss of hearing With hair thinning With NGT @ the right nostril Anicteric sclera Pink palpebral conjunctiva

BP 130/80 mmhg PR 82 bpm

Slightly flaky skin Pale in appearance Slightly dry lips Pale nail bed Flabby abdomen 7

• • Genitourinary

Respiratory

Central nervous system

Neurologic

No bowel movement With NGT at right nostril

• •

No bowel movement With NGT at right nostril

•

Urine output • Urine output 950 cc 690 cc • Menopause • Menopause • RR= 19 cpm • RR= 23 cpm • with crackles at • with crackles at both lung fields both lung fields GLASCOW COMA GLASCOW COMA scale: scale: • Eye opening = • Eye opening = to speech 3 to speech 3 • Verbal response • Verbal response = = incomprehensib incomprehensib le 2 le 2 • motor response • motor response = flexion 3 = flexion 3 (decorticate) (decorticate) • Total GCS = 8 • Total GCS = 8 awake and awake and disoriented disoriented • With limitation • With limitation on movement on movement Grading reflexes: Grading reflexes: • Plantar flexor + • Plantar flexor + 1 diminished, 1 diminished, low normal low normal • Babinski +1 • Babinski +1 diminished low diminished low Normal Normal Sensory: Sensory: • Cranial nerve 1 • Cranial nerve 1 able to smell able to smell but unable to but unable to verbalized what verbalized what she smell she smell Motor: Motor: • Cranial nerve 3 • Cranial nerve 3 pupil 2 mm, pupil 2 mm, sluggishly sluggishly reactive to light reactive to light Both: Both: • Cranial nerve 5 • Cranial nerve 5 8

Musculoskeletal

respond to respond to touch but touch but unable to unable to swallow swallow • cranial nerve 7 • cranial nerve 7 can elevate can elevate eyebrows eyebrows Muscle strength Muscle strength • RU = 1/5 LU = • RU = 1/5 LU = 4/5 4/5 • RL = 3/5 LL = • RL = 3/5 LL = 4/5 4/5 • With limitation • With limitation on movement on movement • Psychomotor • Psychomotor decreased decreased • Decreased • Decreased muscle strength muscle strength

IX. Anatomy and Physiology

Anatomy and Physiology Human Brain The brain consists of 10-10 neurons that are very closely interconnected via axons and dendrites. The neurons themselves are vastly outnumbered by glial cells. One neuron may receive stimuli through synapses from as many as 10 to 10 other neurons (Nunez, 1981). Embryologically the brain is formed when the front end of the central neural system has folded. The brain consists of five main parts, as described in Figure 5.5: 1. 2. 3. 4. 5.

The The The The The

cerebrum, including the two cerebral hemispheres interbrain (diencephalon) midbrain pons Varolii and cerebellum medulla oblongata

9

Fig. 5.5. The anatomy of the brain. The entire human brain weighs about 1500 g (Williams and Warwick, 1989). In the brain the cerebrum is the largest part. The surface of the cerebrum is strongly folded. These folds are divided into two hemispheres which are separated by a deep fissure and connected by the corpus callosum. Existing within the brain are three ventricles containing cerebrospinal fluid. The hemispheres are divided into the following lobes: lobus frontalis, lobus parietalis, lobus occipitalis, and lobus temporalis. The surface area of the cerebrum is about 1600 cm², and its thickness is 3 mm. Six layers, or laminae, each consisting of different neuronal types and populations, can be observed in this surface layer. The higher cerebral functions, accurate sensations, and the voluntary motor control of muscles are located in this region. The interbrain or diencephalon is surrounded by the cerebrum and is located around the third ventricle. It includes the thalamus, which is a bridge connecting the sensory paths. The hypothalamus, which is located in the lower part of the interbrain, is important for the regulation of autonomic (involuntary) functions. Together with the hypophysis, it regulates hormonal secretions. The midbrain is a small part of the brain. The pons Varolii is an interconnection of neural tracts; the cerebellum controls fine movement. The medulla oblongata resembles the spinal cord to which it is immediately connected. Many reflex centers, such as the vasomotor center and the breathing center, are located in the medulla oblongata. In the cerebral cortex one may locate many different areas of specialized brain function (Penfield and Rasmussen, 1950; Kiloh, McComas, and Osselton, 1981). The higher brain functions occur in the frontal lobe, the visual center is located in the occipital lobe, and 10

the sensory area and motor area are located on both sides of the central fissure. There are specific areas in the sensory and motor cortex whose elements correspond to certain parts of the body. The size of each such area is proportional to the required accuracy of sensory or motor control. These regions are described in Figure 5.6. Typically, the sensory areas represented by the lips and the hands are large, and the areas represented by the midbody and eyes are small. The visual center is located in a different part of the brain. The motor area, the area represented by the hands and the speaking organs, is large.

Fig. 5.6. The division of sensory (left) and motor (right) functions in the cerebral cortex. (From Penfield and Rasmussen, 1950.) Brain Function Most of the information from the sensory organs is communicated through the spinal cord to the brain. There are special tracts in both spinal cord and brain for various modalities. For example, touch receptors in the trunk synapse with interneurons in the dorsal horn of the spinal cord. These interneurons (sometimes referred to as second sensory neurons) then usually cross to the other side of the spinal cord and ascend the white matter of the cord to the brain in the lateral spinothalamic tract. In the brain they synapse again with a second group of interneurons (or third sensory neuron) in the thalamus. The third sensory neurons connect to higher centers in the cerebral cortex. In the area of vision, afferent fibers from the photoreceptors carry signals to the brain stem through the optic nerve and optic 11

tract to synapse in the lateral geniculate body (a part of the thalamus). From here axons pass to the occipital lobe of the cerebral cortex. In addition, branches of the axons of the optic tract synapse with neurons in the zone between thalamus and midbrain which is the pretectal nucleus and superior colliculus. These, in turn, synapse with preganglionic parasympathetic neurons whose axons follow the oculomotor nerve to the ciliary ganglion (located just behind the eyeball). The reflex loop is closed by postganglionic fibers which pass along ciliary nerves to the iris muscles (controlling pupil aperture) and to muscles controlling the lens curvature (adjusting its refractive or focusing qualities). Other reflexes concerned with head and/or eye movements may also be initiated. Motor signals to muscles of the trunk and periphery from higher motor centers of the cerebral cortex first travel along upper motor neurons to the medulla oblongata. From here most of the axons of the upper motor neurons cross to the other side of the central nervous system and descend the spinal cord in the lateral corticospinal tract; the remainder travel down the cord in the anterior corticospinal tract. The upper motor neurons eventually synapse with lower motor neurons in the ventral horn of the spinal cord; the lower motor neurons complete the path to the target muscles. Most reflex motor movements involve complex neural integration and coordinate signals to the muscles involved in order to achieve a smooth performance. Effective integration of sensory information requires that this information be collected at a single center. In the cerebral cortex, one can indeed locate specific areas identified with specific sensory inputs (Penfield and Rasmussen, 1950; Kiloh, McComas, and Osselton, 1981). While the afferent signals convey information regarding stimulus strength, recognition of the modality depends on pinpointing the anatomical classification of the afferent pathways. (This can be demonstrated by interchanging the afferent fibers from, say, auditory and tactile receptors, in which case sound inputs are perceived as of tactile origin and vice versa.) The higher brain functions take place in the frontal lobe, the visual center is in the occipital lobe, the sensory area and motor area are located on both sides of the central fissure. As described above, there is an area in the sensory cortex whose elements correspond to each part of the body. In a similar way, a part of the brain contains centers for generating command (efferent) signals for control of the body's musculature. Here, too, one finds projections from specific cortical areas to specific parts of the body. Major Blood Vessels

12

Normal function of the brain's control centers is dependent upon adequate supply of oxygen and nutrients through a dense network of blood vessels. Blood is supplied to the brain, face, and scalp via two major sets of vessels: the right and left common carotid arteries and the right and left vertebral arteries. The common carotid arteries have two divisions. The external carotid arteries supply the face and scalp with blood. The internal carotid arteries supply blood to the anterior three-fifths of cerebrum, except for parts of the temporal and occipital lobes. The vertebrobasilar arteries supply the posterior two-fifths of the cerebrum, part of the cerebellum, and the brain stem. Any decrease in the flow of blood through one of the internal carotid arteries brings about some impairment in the function of the frontal lobes. This impairment may result in numbness, weakness, or paralysis on the side of the body opposite to the obstruction of the artery. Occlusion of one of the vertebral arteries can cause many serious consequences, ranging from blindness to paralysis.

Anterior Cerebral Artery

13

The anterior cerebral artery extends upward and forward from the internal carotid artery. It supplies the frontal lobes, the parts of the brain that control logical thought, personality, and voluntary movement, especially the legs. Stroke in the anterior cerebral artery results in opposite leg weakness. If both anterior cerebral territories are affected, profound mental symptoms may result (akinetic mutism). Middle Cerebral Artery

The middle cerebral artery is the largest branch of the internal carotid. The artery supplies a portion of the frontal lobe and the lateral surface of the temporal and parietal lobes, including the primary motor and sensory areas of the face, throat, hand and arm and in the dominant hemisphere, the areas for speech. The middle cerebral artery is the artery most often occluded in stroke.

Posterior Cerebral Artery

14

The posterior cerebral arteries stem in most individuals from the basilar artery but sometimes originate from the ipsilateral internal carotid artery [Garcia JH et al., In Barnett HJM at al (eds) Stroke Pathophysiology, Diagnosis, and Management New York Churchill Livingstone 1992 125]. The posterior arteries supply the temporal and occipital lobes of the left cerebral hemisphere and the right hemisphere. When infarction occurs in the territory of the posterior cerebral artery, it is usually secondary to embolism from lower segments of the vertebral basilar system or heart. Clinical symptoms associated with occlusion of the posterior cerebral artery, depend on the location of the occlusion and may include thalamic syndrome, thalamic perforate syndrome, Weber's syndrome, contralateral hemplegia, hemianopsia and a variety of other symptoms, including including color blindness, failure to see to-and-fro movements, verbal dyslexia, and hallucinations. The most common finding is occipital lobe infarction leading to an opposite visual field defect. The posterior cerebral arteries stem in most individuals from the basilar artery but sometimes originate from the ipsilateral internal carotid artery [Garcia JH et al., In Barnett HJM at al (eds) Stroke Pathophysiology, Diagnosis, and Management New York Churchill Livingstone 1992 125]. The posterior arteries supply the temporal and occipital lobes of the left cerebral hemisphere and the right hemisphere. When infarction occurs in the territory of the posterior cerebral artery, it is usually secondary to embolism from lower segments of the vertebral basilar system or heart. Clinical symptoms associated with occlusion of the posterior cerebral artery, depend on the location of the occlusion and may include thalamic syndrome, thalamic perforate syndrome, Weber's syndrome, contralateral hemplegia, hemianopsia and a variety of other symptoms, including including color blindness, failure to see to-and-fro movements, verbal dyslexia, and hallucinations. The most 15

common finding is occipital lobe infarction leading to an opposite visual field defect. The posterior cerebral arteries stem in most individuals from the basilar artery but sometimes originate from the ipsilateral internal carotid artery [Garcia JH et al., In Barnett HJM at al (eds) Stroke Pathophysiology, Diagnosis, and Management New York Churchill Livingstone 1992 125]. The posterior arteries supply the temporal and occipital lobes of the left cerebral hemisphere and the right hemisphere. When infarction occurs in the territory of the posterior cerebral artery, it is usually secondary to embolism from lower segments of the vertebral basilar system or heart. Clinical symptoms associated with occlusion of the posterior cerebral artery, depend on the location of the occlusion and may include thalamic syndrome, thalamic perforate syndrome, Weber's syndrome, contralateral hemplegia, hemianopsia and a variety of other symptoms, including including color blindness, failure to see to-and-fro movements, verbal dyslexia, and hallucinations. The most common finding is occipital lobe infarction leading to an opposite visual field defect.

16

X. Pathophysiology

Precipitating Factors: >Hypertension >History of previous Stroke

Predisposing Factors: >Age >Acute Stress >Lifestyle

Overactive of the sympathetic nervous system leading to increase stress response Vasoconstriction Blockage of the blood vessel

Embolism

Lack of Oxygen and Nutrients Supply Hypoxia

Altered cerebral metabolism Cytotoxic edema Aneurysm Rupture

Sudden entry of blood into SA space

Blood supply to the area supplied by artery reduced Increase ICP

•

Brain Tissue Necrosis Paralysis, decreased muscle strength, psychomotor decreased, Impaired and limited coordination by weakness

XI. Laboratory Results 17

Pathology (06-29-09) Fluid Creatinine Sodium Potassium

Result .8 mg/dl 140 mmol/L 2.3 mmol/L

Normal Range .7-12 135-145 3.5

Nursing implication May indicate deficient dietary intake, diuretic administration

Pathology (06-30-09) Fluid Cholesterol Triglyceride s Direct HDLC

Serum

Nursing implication

194 mg/dl 71 mg/dl

Normal Range 97-201 0-150

85 mg/dl

40-60

Indicates that increase in HDLC serves as protective role by mobilizing cholesterol from tissues. Serves as protection against cardiovascula r diseases.

14 mg/dl 4.0 mmol/L 94 mg/dl 2.27 mg/dl

0-35 3.5-5-1 0-160 0-001000.00

Serum

Result

Low

134 mmol/L

Normal Range 137-145

increase

VLDL Potassium LDL CHOL/dHDL

Result

Pathology (07-08-09) Fluid Sodium

Nursing implication may indicate deficient dietary intake, nasogastric 18

Potassium

Low

2.4 mmol/L

3.5-5.1

aspiration, diuretic administratio n, may indicate deficient dietary intake, diuretics,

Hematology (07-08-09) Test

Result

Normal range

Hemoglobin Hematocrit WBC

136 0.42 15.7

120-160 g/L 0.37-0.47 4-10x10^g/L

Neutrophils Lymphocyte Eosinophils Platelets

.76 .22 .02 adequate

0.50-0.70 0.20-0.40 0.01-0.03 0.00-0.01

Nursing implication May indicate presence of infection, severe emotional or physical stress

Chest X-ray (06-29-09) There is note of suspicious right apical density: suggest apicolordotic view. Heart is enlarged with left ventricular prominence. Aorta is prominent. Tortous and calcified there are lateral marginal osteophytes noted in the thoracic spine. No other significant chest x-ray findings. Impression: •

Suspicious Right Apical Density

•

Slight Left Ventricular Prominence

•

Atherosclerotic Aorta

•

Degenerative Thoracic Osteophytosis

19

Cranial CT-Scan (06-29-09) Clinical history: LOC; History of Stroke in 2001 Technique: Axial cranial CT slices are obtained without contrast. The subaranoid spaces are diffusely hyperdense. Well circumscribed hypodense foci are seen in the normal capsuleganglionic region and left copona radiate. Small calcifications are also noted in the bilateral basal ganglia the gray white matter interface is maintained. There is no midlife shift. Hyperdensities seen in the occipital horns of the lateral ventricles. The basilar and vertebral arteries are calcified. The visualized posterior fossa, penial region, orbits, All petromatoins and body calvarium are intact with no demonstrable fracture seen.

Impression: •

Diffuse subarachnoid hemorrhage with intravenous seepage and 2nd mild obstructive hydrocephalus

•

Old infarcts in the right capsule-ganglionic region and left corona radiate

•

Atherosclerotic basilar and vertebral arteries

•

Age r/t bilateral ganglia calcification

Ultrasound of the Abdomen Pancreas- 1.9 x 1.2 x 1.1 cm Gall bladder- 6.6 x 2.4 Right kidney- 8.7 x 3.8 x 3.4 CT- 1.3 cm Left kidney- 8.7 x 3.7 x 3.8 CT- 1.7 cm Spleen- 5.8 x 3.4 cm The liver is normal, in size, smooth contour and homogenous parenchymal echopattern. Both right and left intrahepatic and extrahepatic bile ducts are not dilated. There are no focal mass or calcifications seen. Common bile duct measures 3mm. The gallbladder is not dilated. Wall is not thickened. No intraluminal mass, echoes or bile sludge formation. 20

Pancreas and spleen are both normal in size configuration and echotexture. There are no soiled nor fluid filled masses noted. Pancreatic duct is not dilated. Splenic vein is not dilated. Both kidneys are in normal size and orientation with intact renal margin. Both showed normal and homogenous parenchymal echogenicity. The cortical thickness is within normal showing distinct corticomedullary differentiation. There is no evidence of lithiasis, renal cyst, mass or hydronephrosis bilaterally. The perirenal spaces are clear. Both central echo-plexes are intact. Ureters are not dilated. Urinary baldder is physiologically distended. No intraluminal calculus or extrinsic mass compression. The uterus is atrophic Both ovaries are not seen, most likely atrophic. No adnexal mass seen. No fluid in the posterior cul de sac. Visualized intestinal bowel loops are normal. Impression: •

Normal sonogram of liver, gallbladder, biliary tree, pancreas and spleen

•

Normal kidneys, ureters and urinary bladder

•

(-) for fluid or mass

•

Normal bowel loops

•

Atrophic uterus

•

Ovaries are not seen, most likely atrophic

•

Normal adnexae

21

XII. Drug Study

22

GENERIC

GN:Phenytoin

CLASSIFICATION

 Central nervous system drug

 Anticonvulsant

DOSAGE, ROUTE, FREQUENCY

INDICATIONS/

BN:Dilantin Date started: June 29 2009

MODE OF ACTION

CNS: ataxia, decreased coordination, mental confusion, slurred speech, dizziness, headache, insomia, nervousness

May stabilize neural membranes and limit seizure activity either by increasing efflux or decreasing influx of sodium ions acrosscell membranes in the motor cortex during generation of nerve impulse

CONTRAINDICATIONS

30 mg CAP q8 Indications:

Stock dose: 30 mg

SIDE EFFECTS

 To control tonic-clonic and complex partial seizures.

Contraindications:  Contraindicated in patients hypersensitive to dilantin and those with sinus bradycardia, SA block, second or third AV block, Adam’s stroke syndrome

 Use cautiously in patients with hepatic dysfunction, hypotension, myocardial insufficiency or diabetes

CV: periarteritis nodosa

EENT: diplopia, nystagmus, blurred vision

GI: gingival hyperplasia,nausea, vomiting, constipation

SKIN: discoloration of the skin if given via IV push in the back of hand, exfoliative dermatitis OTHERS: hirsutism or lymphadenopathy

NURSING RESPONSIBILITIES  Assess blood pressure. watch for adverse reactions  Explain drug therapy, need for follow-up tests and importance of taking the drug exactly as prescribed.  Divided doses given after meals or with meals may decrease GI reactions.  Don’t stop sudden (Doctor’s order) because this may worsen seizures. Call prescriber immediately if adverse reaction develop.

 If using to treat seizures, take appropriate safety precautions.

 If seizure control is established with divided doses once dailydosing may be considered.

23

24

GENERIC

GN:Nimodipine

CLASSIFICATION

 Calcium channel blocker

DOSAGE, ROUTE, FREQUENCY

30mg, CAP QID

BN:Nimotop Stock dose: 30 mg

INDICATIONS/

SIDE EFFECTS

CONTRAINDICATIONS

Indications:

CNS: headache

 To remove neurologic deficits after a subarachnoid hemorrhage from ruptured intracranial berry aneurism

CV: hypotension, edema

Date started: June 29 2009 Contraindications:  Adjust a dose and use cautiously for patients with hepatic failure

GI: nausea, abdominal discomfort MUSCULOSKELETAL: muscle cramps RESPIRATORY: dyspnea, wheezing

MODE OF ACTION

NURSING RESPONSIBILITIES

Inhibits calcium ion influx across cardiac and smooth muscle cells, decreasing myocardial contractility and oxygen demands; also dilates coronary and cerebral arteries and arterioles

 Monitor blood pressure and heart rate, especially at start of therapy

 Monitor weight and fluid intake and output. Stay alert for fluid retention. Advise to take drug on empty stomach 1 hour before 2 hours after meal. Instruct him not to consume grapefruit or grapefruit juice within 1 hour 0r 2 hours after taking the drug.

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GENERIC

GN:amlodipine besylate

CLASSIFICATION

 Cardiovascular system drug

 Anti- hypertensive

BN: Norvasc

DOSAGE, ROUTE, FREQUENCY

10mg, TAB, OD

INDICATIONS/ CONTRAINDICATIONS

Indications:  Hypertension

Stock Dose: 10  Chronic stable angina, mg vasospastic angina (Prinzmetal’s or variant angina) Date Started: June 29 2009

SIDE EFFECTS

CNS: headache, fatigue, dizziness, lightheadedness, paresthesia

CV: edema, flushing, palpitations GI: nausea, abdominal pain GU: sexual difficulties MUSCULO_ SKELETAL: muscle pain

MODE OF ACTION

NURSING RESPONSIBILITIES

Inhibits calcium ion influx across cardiac and smooth muscle cells, decreasing myocardial contractility and oxygen demands; also dilates coronary and cerebral arteries and arterioles

 Alert: monitor patient carefully. Some patient, especially those with severe obstructive coronary artery disease, have developed increased frequency, duration or severity of angina or acute MI after initiation of calcium channel blocker therapy or at time of dosage increase.

 Monitor blood pressure frequently during initiation of therapy.  Notify prescriber if signs of heart failure occur such as swelling

26

RESPI: dyspnea SKIN: rash, pruritus

of hands and feet or shortness of breath.

 Don’t confuse amlodipine with amiloride.

27

GENERIC

CLASSIFICATION

DOSAGE, ROUTE, FREQUENCY

INDICATIONS/ CONTRAINDICATIONS

SIDE EFFECTS

MODE OF ACTION

NURSING RESPONSIBILITIES

Two GN:Lactulose

BN: Lilac

Laxatives

30 ml oral (syrup) OD Stock Dose: 120 ml Date started: June 30 2009

Indications:

abdominal

Relief of constipation including chronic constipation. Portal systemic encephalopathy: Hepatic coma or precoma stages where hyperammonemia is present.

discomfort

Contraindications:

associated

 Use cautiously for mechanisms are patients treated with lactulose syrup believed to be involved in the laxative action

 No laxative should be

of lactulose:

taken for >1 week

First,

without the advice of a

metabolism of

physician. No laxative

Nausea and

lactulose by

should be used in the

vomiting

bacteria results

presence of abdominal

in reduced

pain nausea, fever or

colonic pH

vomiting, as such

which

symptoms may signal

stimulates

appendicitis or an

peristalsis and

inflamed bowel.

with flatulence and intestinal cramps.

diarrhea with potential Patients who require a low complications lactose diet; with eg, loss of galactosemia or fluids, disaccharide deficiency; hypokalemia with intestinal obstruction. and hyponatremia.

decreases stool transit time. In turn, decreased water

 Care should be taken in patients who are lactose-intolerant.

reabsorption from the feces further facilitates the passage of soft well-formed stools. Second, increased osmotic

 For elderly, debilitated patients who receive lactulose for >6 months should have serum electrolytes (potassium, chloride, 28 carbon dioxide) measured periodically.

GENERIC

GN: Losartan Hydrochlorothiazide

CLASSIFICATION

 Angiotensin II Antagonists  Diuretics

BN:Combizar

DOSAGE, ROUTE, FREQUENCY

100mg, TAB, OD Stock Dose: 100 mg Date started: June 29 2009

INDICATIONS/ CONTRAINDICATIONS

Indications:

SIDE EFFECTS

Abdominal pain, edema, asthenia,  Management Of headache. Hypertension. Palpitation. Diarrhea, nausea. Contraindications: Back pain. Dizziness. Dry cough, sinusitis,  Contraindicated To Those bronchitis, Who Are Hypersensitive To pharyngitis, Sulfonamides. Patients W/ upper resp Anuria & Depleted infection. Intravascular Volume As Rash. well as pregnant women.

MODE OF ACTION

NURSING RESPONSIBILITIES

A selective competitive angiotensin 1 receptor antagonist simply inhibits indirectly some substance occur in our body responsible for water retention thus by decreasing body water volume lowers blood pressure

 May be taken with or without food

29

30

GENERIC

CLASSIFICATION

DOSAGE, ROUTE, FREQUENC Y

INDICATIONS/

SIDE EFFECTS

CONTRAINDICATIONS

MODE OF ACTION

NURSING RESPONSIBILITIES

. GN:Mannito l

Diuretic,osmotic

75 ml every 6 hours TIV Stock Dose: 250 ml

BN: Osmitol,

Date started: June 29 2009

Indication; •

•

resectisol

•

Prevention and treatement of the oliguric phase of renal failure Reduction of intracranial pressure and treatment of cerebral edema; of elevated IOP when the pressure cannot be lowered by other means Promotion of the urinary excretion of toxic substances

Contraindication •

•

Contraindicated with anuria due to severe renal disease. Use cautiously with pulmonary congestion, active bleeding

CNS: Dizziness, headache,blurred vision,seizures CV: Hypotension edema,thrombophebiti s, tachycardia, chest pain Dermatologic: urticaria, skin necrosis with inflitration GU: diuresis, urinary retention GI: Nausea, anorexia, dry mouth, thrist Hematologic: fluid and electrolyte imbalances, hyponatremia Respiratory: pulmonary congestion, rhinitis

Elevates the osmolarity of the glomerular filtrate, thereby hindering the reabsorption of water and leading to a loss of water and sodium, chloride create an osmotic gradient in the eye between plasma and ocular fluids, thereby reducing IOP, creates an osmotic effects, leading to decreased swelling in posttransurethr al prostatic resection

•

• • •

Assess for S&S of electrolyte imbalance and dehydration Monitor VS & I&O You may experience the side effects. Report difficulty of breathing, pain at the iv site, chest pain.

31

XIII. Problem List

32

RANK

ACTUAL PROBLEM

DATE IDENTIFIED

DATE RESOLVED

1

Impaired circulation

July 9 2009

Unresolved

2

Muscle weakness

July 9 2009

Unresolved

3

Inability to do self-care

July 9 2009

Unresolved

5

Producing incomprehensible sounds

July 9 2009

Unresolved

RANK

POTENTIAL PROBLEM

DATE IDENTIFIED

DATE RESOLVED

1

Risk for Injury

July 9 2009

UNRESOLVED

2

Risk for Aspiration

July 9 2009

UNRESOLVED

XIV. Nursing Care Plans

Impaired Circulation 33

ASSESSMENT S=

NURSING DIAGNOSIS Impaired cerebral

Short term

tissue perfusion r/t

objective:

vascular occlusion The patient manifested the ff:

PLANNING

INTERVENTIONS >Establish Rapport

T-36.7 P-68

After Nursing will demonstrate

GLASCOW COMA scale: Eye opening = to speech 3 • Verbal response =

EXPECTED OUTCOME Short term objective: After Nursing intervention, the pt.

intervention, the pt. >Monitor Vital signs

> To identify any other deviations from normal.

as individually

shall be able to demonstrate increased perfusion as individually appropriate

appropriate Long Term

>Assist pt. in

Objective:

assuming

R-19 BP- 130/80

> To gain pt’s trust and coordination

increased perfusion O=

RATIONALE

After 2-3 days of Nursing Intervention,

semifowler’s position w/ head midline.

behaviors which may improve proper circulation such as

>To aid with proper perfusion or flow of blood (circulation or venous drainage).

the pt. will be able o demonstrate

Long Term Objective: After 2-3 days of Nursing Intervention, the pt. shall be able to demonstrate behaviors

>Administer

>To probably

which may improve

medications as

decrease cardiac

proper circulation such

ordered such as

workload and in

as compliance to health

34

• •

incomprehensib le 2 motor response = flexion 3 (decorticate) Total GCS = 8 awake and disoriented

compliance to health

antihypertensive or

maximizing tissue

management &

management &

diuretics.

perfusion

therapies provided.

>Encourage quiet

>To conserve energy

therapies provided.

and restful atmosphere.

>Exercise caution in using hot or cold pads.

which could aid in lowering the O2 tissue demand.

>The t issues may have decreased sensitivity due to ischemia.

>Encourage use of

>To decrease the

relaxation techniques tension level or exercises.

35

>Discuss the importance of preventing exposure to cold or extreme

>To retain heat or warmth efficiently

cold temp

>Discuss to the patient’s SO the importance of care of dependent limbs,

>To promote wellness

body hygiene, and foot care when circulation is impaired.

NURSING INTERVENTION PROGRESS NOTE

36

PROBLEM: IMPAIRED CIRCULATION DATE: JULY 09, 2009

ASSESSMENT: ON THE FIRST DAY WE HANDLED OUR CLIENT, SHE HAS THE GLASCOW COMA SCALE, Eye opening = to speech 3 Verbal response = incomprehensible 2, motor response = flexion 3 (decorticate), Total GCS = 8 awake and disoriented. SHE IS SLEEPING WHEN WE CAME INDISE THE ROOM. INTERVENTION: AFTER THE ASSESSMENT, WE ADVISED THE RELATIVES AND TEACH THE PROPER POSITIONING OF THE PATIENT, SEMI FOWLER’S POSITION WITH HEAD MIDLINE. EVALUATION: THE CLIENT STILLS THE SAME EVEN WE DID OUR INTERVENTIONS.

Muscle weakness

37

ASSESSMENT

NURSING

PLANNING

DIAGNOSIS

INTERVENTIONS

RATIONALE

EXPECTED OUTCOME

S= “ hindi sya gasinong makagalaw”

O= Impaired and limited coordination by weakness Decreased muscle strength Muscle strength RU=1/5 RL=3/5 LU=4/5 LL=4/5

Impaired physical

Short Term

mobility

Objective:

neuromuscular and musculoskeletal impairment as evidence by limited motor skills.

>Establish Rapport

> To gain pt’s trust

Short Term

and coordination

Objective:

After Nursing

After Nursing

Intervention, the pt. will be able to

>Monitor Vital signs

maintain increased

> To identify any other deviations from normal.

strength and function of affected

>Assess patient

or compensatory

condition

part.

Intervention, the pt. shall be able to maintain increased strength and function of affected or

>To determine any

compensatory part.

other underlying cause of manifestations >Provide adequate

Long Term

rest periods as well

Objective:

as comfort & safety

Long Term Objective: > To prevent further

After 2-3 days of nursing intervention,

38

After 2-3 days of

measures

stress & fatigue

the pt. shall be able to

nursing intervention,

demonstrate behaviors

the pt. will be able to

that enable resumption

demonstrate

>Turn pt. slowly from

behaviors that

side to side

enable resumption

of activities. > To provide proper circulation of blood

of activities.

flow on both sides

>Determine pt. level of mobility >To assess functional >Assist pt. in his

ability

activities >To promote optimal >Encourage

level of function

adequate intake of fluids & Nutritious 39

foods

>Promotes wellbeing and maximizes energy production.

>Involve client’s SO in care

>To assist in learning ways of managing problems of immobility.

NURSING INTERVENTION PROGRESS NOTE PROBLEM: MUSCLE WEAKNESS

40

DATE: JULY 09, 2009

ASSESSMENT: ON THE FIRST DAY WE HANDLED OUR CLIENT HAS IMPAIRED AND LIMITED COORDINATION BY WEAKNESS AND DECREASED MUSCLE STRENGTH. INTERVENTION: AFTER THE ASSESSMENT, WE MONITORED THE VITAL SIGNS, ASSESSED THE CLIENT’S CONDITION. WE ALSO PROVIED HER ADEQUATE REST PERIODS AS WELL AS COMFORT AND SAFETY MEASURES. WE TURNED THE CLIENT SLOWLY FORM SIDE TO SIDE EVERY 2HOURS. EVALUATION: THE CLIENT STILLS THE SAME EVEN WE DID OUR INTERVENTIONS.

Inability to do self-care

41

ASSESSMENT S=

NURSING DIAGNOSIS Self Care deficit r/t

Short Term

neuromuscular,

Objective:

musculoskeletal The patient manifested the following:

PLANNING

impairment

RATIONALE

>Established Rapport

> To gain trust of the

Short Term

patient and SO in

Objective:

order to acquire

After Nursing

compliance with

Intervention, the pt.

appropriate

will be able to

treatments or

identify personal

teachings

resources which can O=

EXPECTED

INTERVENTIONS

help in providing

>Monitored Vital

assistance.

signs

Decreased muscle

OUTCOME

After

Intervention, the pt. shall

be

identify

able

to

personal

resources which can help

> To identify any

Nursing

in

providing

assistance.

other deviations from

strength >Assessed patient Long Term

condition

Objective:

the pt. will be able to

Long Term >To determine any other underlying

After 2-3 days of nursing intervention,

normal.

cause of >Provided adequate

manifestations

Objective: After nursing

2-3

days

of

intervention,

42

demonstrate

rest periods as well

techniques or

as comfort & safety

changes to meet self

measures

care needs.

the pt. shall be able to > To prevent further

demonstrate

stress & fatigue

techniques or changes to

meet

self

care

needs.

>Turned pt. slowly from side to side > To provide proper circulation of blood >Determined pt.

flow on both sides of

strengths and skills

he body

>Assisted pt. in his

>To assess degree of

activities

disability

>To promote optimal >Encouraged

level of function

adequate intake of

43

fluids & Nutritious foods

>Promotes well-being and maximizes

>Provided time for

energy production.

listening to patient and SO, and provided privacy during personal care activities.

>To assist with the patient’s current disability or condition.

>Involved client’s SO in care

>To assist in learning ways of managing problems of immobility and for providing appropriate nursing care.

> Provided health

44

teachings and support o the SO for care options

>To provide clarification Reinforcement and and periodic Review by client/caregivers.

45

NURSING INTERVENTION PROGRESS NOTE PROBLEM: INABILITY TO DO SELF-CARE DATE: JULY 09, 2009

ASSESSMENT: ON THE FIRST DAY WE HANDLED OUR CLIENT HAS DECREASED MUSCLE STRENGTH. INTERVENTION: AFTER THE ASSESSMENT, WE MONITORED THE VITAL SIGNS, ASSESSED THE CLIENT’S CONDITION. WE ALSO PROVIED HER ADEQUATE REST PERIODS AS WELL AS COMFORT AND SAFETY MEASURES. WE TURNED THE CLIENT SLOWLY FORM SIDE TO SIDE EVERY 2HOURS, WE ALSO DETERMINED CLIENT’S STRENGTHS AND SKILLS. EVALUATION: THE CLIENT STILLS THE SAME EVEN WE DID OUR INTERVENTIONS.

46

Producing incomprehensible sounds ASSESSMENT

S= “ Naungol lang sya pag may kailangan sya”

NURSING DIAGNOSIS

PLANNING

impaired verbal

Short Term

and/or written

Objective:

communication r/t impaired cerebral circulation, aphasia

INTERVENTIONS >Establish rapport

w/ muscle weakness

>Monitor v/s

Objective:

>To obtain baseline data

intervention the pt shall verbalize or indicate understanding of communication

difficulty and plans

>Assess pt’s general

for ways of handling.

condition

>To note for the etiology or

difficulty and plans for ways of handling

precipitating factors that can lead to fever.

With drooling of

Difficulty in

and coordination

communication

Uses incomprehensible sounds

saliva

Short Term

After the nursing

pt will be able to verbalize or indicate

EXPECTED OUTCOME

>To gain pt’s trust

After nursing int. the

understanding of the O=

RATIONALE

Long Term

>Note results of

Objective:

neurological testing such as EEG/CT scan

>To assess causative/contributin

Long Term Objective:

g factors 47

expressing needs

After 3 days of

and the likes

After the nursing

nursing intervention

intervention the pt shall

the pt will establish

be able to establish

method of

>Assess

>To assess

methods of

communication in

environment factors

causative/contributin

communication in

which needs can be

that may affect

g factors

which can be

expressed.

ability to

expressed.

communicate >To assist client to establish a means of >Establish

communication to

relationship with the

express needs,

client , listening

wants, ideas and

carefully and

questions

attending to clients verbal/nonverbal expressions >Maintain a calm, unhurried manner, provide sufficient

>Individuals may talk more easily when they are rested and relaxed

48

time for the client to responds >Anticipate needs

>To attend pt’s needs immediately

until effective communication is reestablished >Administer due meds

>For pt’s recovery and to treat underlying conditions

49

NURSING INTERVENTION PROGRESS NOTE PROBLEM: MUSCLE WEAKNESS DATE: JULY 09, 2009

ASSESSMENT: ON THE FIRST DAY WE HANDLED OUR CLIENT HAS IMPAIRED AND LIMITED COORDINATION BY WEAKNESS AND DECREASED MUSCLE STRENGTH. INTERVENTION: AFTER THE ASSESSMENT, WE MONITORED THE VITAL SIGNS, ASSESSED THE CLIENT’S GENERAL CONDITION. WE NOTED THE RESULTS OF NEUROLOGICAL TESTING SUCH AS EEG/CT SCAN, WE ASSESSED ENVIRONMENT FACTORS THAT MEY AFFECT ABILITY TO COMMUNICATE. EVALUATION: THE CLIENT STILLS THE SAME EVEN WE DID OUR INTERVENTIONS.

50

POTENTIAL PROBLEM

Risk for Injury NURSING DIAGNOSIS Risk for Injury

PLANNING

INTERVENTIONS

RATIONALE

Short Term Objective: After nursing intervention the pt will demonstrate behaviors, lifestyle changes to reduce risk factors and protect self from injury

Short Term Objective: >Monitor v/s

>Assess pt’s general condition Long Term Objective: After hospitalization, pt will be free of injury

EXPECTED OUTCOME

>To obtain baseline data

>To note for the etiology or precipitating factors that can lead to fever.

The patient shall have demonstrated behaviors, lifestyle changes to reduce risk factors and protect self from injury Long Term Objective: The patient shall have been free of injury.

>Assess mood, coping abilities, personality styles 51

>that may result in carelessness and increased risk taking without considerations of consequences >Identify interventions and safety devices >To promote safe physical environment and individual safety >Encourage participation in self-help programs, such as assertiveness training, positive self image

>To enhance self esteem. sense of worth

>raise the side rails of the bed >To promote safe physical environment and individual safety

>Frequent skin inspection > To assess if there is presence of pressure

52

>Use effective lighting

>Remind client to walk slowly, ambulate

>Keep things into right premises and clear the way going to the restroom

ulcers.

>To promote safety and easy scanning of the environment.

>To prevent injury due to slipping, and to promote safety. >To prevent injury and promote safety.

53

Risk for Aspiration NURSING DIAGNOSIS Risk for Aspiration

PLANNING Short term objective: After Nursing intervention, the pt. demonstrate techniques to prevent aspiration.

Long Term Objective: After hospitalization, the pt. will experience no aspiration aeb noiseless

INTERVENTIONS

RATIONALE

EXPECTED OUTCOME Short term objective:

>Monitored Vital signs

>Note level of consciousness of surroundings, and cognitive impairment.

> To identify any other deviations from normal.

>To assess if there is gag reflex or difficulty of swallowing.

>To clear secretions >Suction as needed

>Auscultate lung sounds

The patient shall have demonstrated techniques to prevent aspiration.

Long Term Objective: The patient shall have experienced no aspiration aeb noiseless respirations, and clear breath sounds.

>to determine presence of secretions

54

respirations, and clear breath sounds.

>Give semisolid foods; avoid pureed that may increase risk of aspiration.

>To prevent aspiration and to aide swallowing effort.

>Provide very warm or cold liquids

>This activates temperature receptors in the mouth that help to stimulate swallowing.

>Refer to speech therapist

>To strengthen muscles and techniques to enhance swallowing.

55

XV. Overall Progress Notes

On the 1st day of our duty, the patient was conscious but incoherent due to inability to speak and she is just producing incomprehensible sounds whenever she wanted anything. We also noted that she has hemiphlagia on the right side of the body. She also had NGT on her right nostril. As part of the nursing interventions, we took her vital signs which are as follows: Temp.= Afebrile, Pulse= 68, Respiratory= 19 and BP of 130/80mmHg. The students also provided non pharmacological interventions such as positioning etc. They also provided health teachings for the family of the client. On the second day, the patient is still the same with what we observe yesterday, For her vital signs: Temp.= Afebrile, Pulse=82, Respiratory= 23 and a BP of 130/80mmHg. The students performed again those interventions they’ve done with the client. Overall, the patient’s condition is still the same.

56

57