Patient #6: Cerebrovascular Damage/ Bleed M 48 Diagnosis Risk For

Patient #6: Cerebrovascular Damage/ Bleed M 48 DIAGNOSIS

ANALYSIS

GOAL

Risk for Impaired skin integrity related to immobilization

A state in which a persons skin is at risk from being altered.

Within the entire – shift the patient’s skin will maintain to be intact as evidenced by no redness on bony prominence.

Implement a post turning schedule, restricting time in one position to 2 hrs. or less and customizing the schedule to patient’s routine

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Maintain patient’s functional body alignment

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Clean dry and moisturize the skin, specially over bony prominence

O: The patient is lying on bed.

NURSING INTERVENTIONS

Wearing adult diaper

RATIONALE

EVALUATION

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A schedule that does not interfere with the patients schedule is to be followed.

The skin of the client remain to be intact

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To reduce friction

With NGT S: SO verbalized “nastroke kasi yan, ngayon nga lang yan nagsimulang magkamalay eh.”

M: BP 140/80 PR 57 RR 17 Temp 36.8

Drug Name

Dosage

Classification

Indication

Contraindication

Side Effects

Nursing Responsibilities

Simvasta tin

40mg/tab 1 tab OD at hs (p.o.)

Inhibits HMGCoA reductase, the enzyme that catalyzes the first step in the cholesterol synthesis pathway, resulting in a decrease in serum cholesterol, serum LDLs, and either an increase or no change in serum HDLs.

Indications

Contraindicated with allergy to simvastatin, fungal byproducts, pregnancy, lactation.

CNS: Headache, asthenia, sleep disturbances

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GI: Flatulence, diarrhea, abdominal pain, cramps, constipation, nausea, dyspepsia, heartburn, liver failure

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Gastrointestina l agent, hyperosmotic laxative

prevention and tx of portalsystemic encephalopathy (PSE), including stages of hepatic precoma and coma, and by prescription for relief of chronic constipation

Lactulose 80 cc BID

Adjunct to diet in the treatment of elevated total cholestrol and LDL cholesterol with primary hypercholesterolemia (types IIa and IIb) in those unresponsive to dietary restriction of saturated fat and cholesterol and other nonpharmacologic measures To reduce the risk of coronary disease, mortality, and CV events, including stroke, TIA, MI and reduction in need for bypass surgery and angionplasty in patients with coronary heart disease and hypercholesterolemia

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Respiratory: Sinusitis, pharyngitis Other: Rhabdomyolysis, acute renal failure, arthralgia, myalgia

Assess nutrition: fat, protein, carbohydrates Monitor bowel pattern daily Monitor triglycerides, cholesterol baseline throughout treatment

Precautions: Past liver disease, alcoholism, severe acute infections, trauma, severe metabolic disorders, electrolyte imbalances, elderly, renal disease

diarrhea

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Effects are seen in 24-48 hrs Do not self medicate with another laxative because of slow onset Notify Dr if diarrhea persists for more than 24 hrs, could be a sign of overdose, and need for med adjustment