LYCEUM OF THE PHILIPPINES UNIVERSITY

COLLEGE OF NURSING

A CASE STUDY

ON

CEREBROVASCULAR ACCIDENT

PRESENTED BY:

DE CHUSA, GAZELLE B.

DE LOS SANTOS, SHARMANE AINA D.

DEL MUNDO, ROSSE L.

ENDOZO, CHRISANDRA M.

FALTADO, MARY JANE E.

GABAY, RACHEL MARIE T.

GARCIA, PAULYNE KRISELLE M.

HERNANDEZ, JOHN MICHAEL H.

MARCOS, KRISCELE V.

YACO, ANN ZENITH L.

BSN III-2

TABLE OF CONTENTS

I. INTRODUCTION

II. OBJECTIVES

III. PATIENT’S PROFILE

IV. CLINICAL APPRAISAL

V. PHYSICAL ASSESSMENT

VI. DIAGNOSTIC AND LABORATORY RESULTS

VII. ANATOMY AND PHYSIOLOGY

VIII. PATHOPHYSIOLOGY

IX. NURSING CARE PLAN

X. DRUG STUDY

XI. PROGNOSIS

XII. DISCHARGE PLANNING

XIII. ACKNOWLEDGEMENT

XIV. REFERENCES

I. INTRODUCTION

Cerebrovascular Disorders is an umbrella term that refers to a functional abnormality of the central nervous system (CNS) that occurs when the normal blood supply to the brain is disrupted. Strokes can be divided into two major categories: ischemic, in which vascular occlusion and significant hypoperfusion occur and hemorrhagic, in which there is extravasation of blood into the brain or subarachnoid space.

Ischemic stroke, cerebrovascular accident (CVA) or “brain attack” is a sudden loss of functioning resulting from disruption of the blood supply to a part of the brain. This is subdivided into five different types based on the cause. The small penetrating artery thrombotic strokes (25%), Large artery thrombotic strokes (20%). The cardiogenic embolic strokes (20%) are associated with cardiac dysrhythmias, usually atrial fibrillation. It can be associated with valvular heart disease and thrombi in the left ventricle. Emboli originate from the heart and circulate to the cerebral vasculature, most commonly the left middle cerebral artery, resulting from stroke. The cryptogenic strokes (30%) which have no known cause and strokes from other causes, such as illicit drug use, coagulopathies, migraine and spontaneous dissection of the carotid or vertebral arteries.(Smeltzer, Bare, Hinkle & Cheever, 2010)

An ischemic stroke can cause a wide variety of neurologic deficits, depending on the location of the lesion (which the vessels are obstructed), the size of the area of inadequate perfusion and amount of collateral (secondary or accessory) blood flow. The patient may present with any of the following signs o symptoms: Numbness or weakness of the face, arm or leg, especially one side of the body; Confusion or change in mental status; trouble speaking or understanding speech; visual disturbances; difficulty walking, dizziness, or loss of balance or coordination and sudden severe headache. Motor, sensory, cranial nerve, cognitive, and other functions may be disrupted.

In right hemispheric stroke the following can be observed paralysis or weakness on left side of the body, Left visual field deficit, spatial-perceptual deficits, increased distractibility, impulsive behavior and poor judgment lastly lack of awareness of deficits.

Risk factors can be broadly classified into controllable and uncontrollable risks. The controllable risks include smoking, hypertension, carotid or other arterial diseases, history of Transient Ischemic Attack, Diabetes, High Cholesterol, physical inactivity, obesity, alcohol, drug abuse and injury to brain.

According to National Statistics Office reported by Abs-Cbn news last October 20, 2011, Cerebrovascular Disease became second cause of death among Filipinos, with 56,670 people dying of the illness from January 2009- 2010. Stroke, which is second to heart attack as the leading cause of death in the Philippines, also affects young people as a result of birth or congenital defect based on newsinfo.inquirer.net.

Moreover, we chose this case because we are interested to know the factors that contribute to the disease and its pathohysiology. We also wanted to enhance our knowledge, skills and attitude in handling patient with this disease including the independent nursing care that we may render to the patient.

II. OBJECTIVES

The completion of this case study aims to equip the student nurses with

knowledge, skills and attitude necessary to form critical nursing abilities in

rendering care to the client in need. The student nurses will enhance their

affective, cognitive and psychomotor aspects through the formulation of nursing

care process.

Specific objectives:

Familiarize themselves in Cerebrovascular Accident, its associated clinical manifestation, and its incidence rate for better understanding of the disease process.

Discuss the patient’s profile (including the date of admission, physician, chief complaint, admitting and final diagnosis), past and current health history, family, personal, social, and psychological history as reference for client’s health status.

Conduct physical assessment to assess the general appearance, consciousness and cognition, to examine the cranial nerves, motor system, sensory system and reflexes of the patient.

Analyze, interpret and relate the results of conducted laboratory and diagnostic test.

Understand the anatomy and physiology of related organs. Explain the cause and process of the disease or its pathophysiology and

the signs and symptoms manifested by the patient. Formulate and provide an efficient nursing care plan for the improvement

of the patient’s health status utilizing nursing process. Carry out necessary nursing interventions appropriate for the provision of

patient care. Discuss the drugs taken by the patient with their corresponding doses,

frequency, routes, classification, action, indications, contraindications, side-effects, nursing responsibilities and monitoring parameters.

Provide information on the prognosis of the patient Create an appropriate discharge plan for the patient. Learn new clinical skills with regards to the prevention, treatment and

management of the disease. Develop a sense of understanding to our patient by providing nursing care

holistically Appreciate the improvements made by the patient and family. Practice compassion and competence in the care of client with

Cerebrovascular Accident.

III. PATIENT’S PROFILE

NAME: Patient RA

AGE: 67 years old

ADDRESS: Ibabao, Cuenca

NATIONALITY: Filipino

RELIGION: Roman Catholic

GENDER: Male

STATUS: Married

DATE OF ADMISSION: January 20, 2013

HOSPITAL #: 092873-2

PHYSICIAN: Dr. Leynes

ADMITTING DIAGNOSIS: T/C Cerebrovascular Large Frontotemporoparietal

infarct left, probably cardioembolic

>HASCVD (Hypertensive Aterosclerotic Cerebrovascular Disease)

DATE OF DISCHARGE: February 2, 2013

SOURCE OF INFORMATION: Jennie Carandang (daughter)

CHIEF COMPLAINT: right sided body weakness and inability to speak

IV. CLINICAL APPRAISAL

GENERAL SURVEY

Received patient lying in bed, appears weak and has difficulty speaking.

With number 15 PNSS 1L hooked at left metacarpal vein infusing at 80cc/hr. Age

is in accordance with his physical development. He is dressed in hospital gown.

The client opens his eyes spontaneously upon hearing his name. He answers to

questions but with incomprehensible sounds. On the other hand, he would have

wanted to obey commands if not with the presence of his right side body

weakness. Otherwise, he can move his left extremities effortlessly

PAST HEALTH HISTORY

Patient RA has no known allergies on food or drugs. According to his wife,

he had vehicular accident on 1993 where he needed to stay in the ICU at Greece

for almost a month. With regards to this event, he went through several

treatments since tests revealed contusion of his chest and pneumothorax.

Whenever encountering an illness, they have made it a habit to just take over-

the-counter drugs like Biogesic for headache, Paracetamol for fever, Neozep for

colds and the like. The second was in June 8, 2013 when he spent four days at

the same institution (MMMC) due to diverticulosis. The relatives was not able to

recall the management done. Patient RA has a maintenance drug of Approvel

300 mg once a day for his hypertension.

FAMILY HISTORY

Patient RA has a family history of hypertension as well as his wife. His

parents both died with age alongside with cardiovascular disease. And it has

been apparent to them that he is prone to either of the two CVDs –

cardiovascular disease and cerebrovascular disease – since these are prominent

on both of his parents’ side.

PERSONAL HISTORY

He is currently residing at Cuenca Ibabao after 20 years of living in

Greece with his 57 year old wife and where he also worked as a driver. He

usually includes meat (chicken, pork) in his meals and is not satisfied if not

paired with 5-6 cups of rice. He also eats vegetable and fruits whenever present

at the table. Walking early in the morning is his form of exercise. His urine, bowel

and sleeping pattern were normal. Patient RA is a chain smoker. He started

smoking when he was 16 and consumed 1 pack of cigarette a day. He was also

addicted to alcohol. He could consume 15 bottles of alcohol like beer, red horse.

emperador and the like with company on occasion, once to thrice every week.

Last year, he decided to stop his vices.

SOCIAL HISTORY

Patient RA is a Roman Catholic. According to his wife they are exposed to

noise and air pollution because they are residing near the national high way.

They are living harmoniously with their relatives and neighbors. Patient RA

belongs to a nuclear type of family. The family believes in “quack doctors” and

consults to it whenever one member of the family is ill. Patient RA is an

elementary graduate. He joins in programs of their barangay especially if it talks

about health.

PSYCHOLOGICAL HISTORY

There has been no incident of mental retardation in patient RA’s line of

family. His typically gets stressed financially and due to some misunderstandings

with his wife. He can easily bend into problems by patching things up with his

wife.

HISTORY OF PRESENT ILLNESS

Hours prior to admission, almost midnight of January 20, 2013, he was

rushed to MMMC due to aphasia and right sided body weakness. He lost

consciousness in the ER and was admitted at ICU for 3 days. Morning of January

23, 2013, he was transferred to medical ward with a diagnosis of T/C

cerebrovascular disease large Frontotemporoparietal infarct left, probably

cardioemolic HASCVD.

V. PHYSICAL ASSESSMENT

Date January 28, 2013General Appearance

Received patient lying in bed, appears weak (lacks strength and energy to do something, can’t stand) hooked with IVF of # 15 PNSSIL@80cc/hr. His age is in accordance with his physical and sexual development. He dresses appropriately to weather. The client opens his eyes spontaneously upon hearing his name. He answers but with incomprehensible sounds, slurring speech, and he obeys command. He has a Glasgow Coma Scale of 12 with a score of 4 on Eye opening, 2 on Verbal Response and 6 on Motor Response.

Vital signs BP: 140/90 mmHgTemperature: 36.6oCRespiratory rate: 21 breaths/minPulse rate: 75 beats/min

Body parts Methods Findings Analysis

Skin

Inspection -light brown in color- few scars were noted on lower extremities

-Normal

-Abnormal due to previous vehicular accident.

Palpation -warm to touch-intact skin-Returns to its position when pinched.

-Normal-Normal-Normal

Hair Inspection -White hairs was noted

-Normal, due to aging

Scalp Palpation - Free from masses, lumps, scar, dandruff and lesions, no areas of tenderness.

-Normal

Nails

Inspection -with clean nails -NormalPalpation -capillary refill test

returns immediately on both hands

-Normal

Head/ Face

Inspection -Located in midline, no involuntary movements, still and upright-Asymmetric facial features when smiling, frowning, and puffing up cheeks.

-Normal

-Abnormal, Due to CN VII damage

Palpation -No sensation felt on the left side of the face either blunt or sharp.

-Abnormal due to CN V damage

Neck Inspection -Neck is symmetric, without bulging masses or any enlargement. -unable to swallow

-Normal

-Abnormal due to

impairment of CN X.

Palpation - No enlarged and tender lymph nodes

-Normal

Auscultation - No bruits heard -Normal

Eyes

Inspection - Parallel and evenly placed, symmetrical not protruding. - No presence of redness and swelling- Cornea is transparent with no opacities; iris is round, flat and evenly colored. - Pupil equally round -Iris is round and flat and evenly colored.-Has no blink reflex on left side of eyes-pupil has no constriction to light on left side of the eyes.-pupils do not constrict on left side; eyes do not converge. -able to follow the six field of gazes on both sides- Sclera is white in color-Pinkish conjunctiva

-Normal

-Normal

-Normal

-Normal

-Normal

-Abnormal due to CN V damage.

-Normal

-Abnormal due to CN III damage.

-Abnormal due to dysfunction of cranial nerve III and IV -Normal

-Normal

-NormalPalpation -No tenderness on

lacrimal glands.-Normal

Ears

Inspection -Color is the same as the facial skin -Symmetrically aligned-No redness, lesions on pinna, tragus or auditory meatus-Small amount of cerumen present

-Normal

-Normal

-Normal

-Normal

Palpation -No tenderness, firm

-Normal

Inspection -NGT was -Abnormal. due to

Nose

inserted on right nose-Symmetrically aligned-No lesions or abrasions noted

inability to swallow

-Normal

-Normal

Palpation -No tenderness, -Normal

Mouth Inspection - Lips are smooth and moist without lesions or swelling.- Has decayed teeth- Buccal mucosa appears pink.- Tongue is pink and moist with papillae.-unable to protrude tongue and move from side to side.-dysarthria

-expressive aphasia

-Normal

-Abnormal due to poor hygiene.-Normal

-Normal

-Abnormal due to impairment in cranial nerve IX and XII. -Abnormal due to CN IX damage.- Abnormal due to CN IX damage.

Thorax Inspection -no observed retraction

-Normal

Auscultation -Has adventitious sounds; crackles heard

-Abnormal due to accumulation of mucus

Heart Auscultation -Heard heart murmurs

-caused by blood rushes through the heart quickly during normal function.

Abdomen

Inspection -round abdomen

-umbilical skin tones are similar to surrounding abdominal skin tone.

-Abnormal, Indicate excess body fats deposit-Normal

Auscultation -2-3 bowel sounds heard in 1 mins

-hypoactive due to decreased physical activity

Palpation -no pain -NormalMusculoskeletal

(upper)Inspection -unable to move

the right arm -unable to shrug the shoulders-shoulders, arms and elbows are symmetric with no deformities.

-Abnormal due to left side stroke-Abnormal due to CN XI damage.-Normal

-muscle strength is 0/5 on right

-Abnormal due to left side infarct.

Palpation -no tenderness- has intact skin returns to original position after pinched

-Normal-Normal

Musculoskeletal (lower)

Inspection -unable to move the right leg, inability to stand.- muscle strength is 0/5 on right

-Abnormal due to left sided stroke

-Abnormal due toLeft side infarct.

Palpation -with grade 1 bipedal edema

-has positive Babinski reflex

- has intact skin returns to original position after pinched

-Abnormal, Indicates Fluid Retention -severe damage to the central nervous system.-Normal

SUMMARY OF PHYSICAL ASSESSMENT

A head to toe assessment was done last January 28, 2013 10:00 in the

morning. Upon receiving the patient, a right sided body weakness was evident on

his general appearance. The following are the abnormal findings few scars were

noted on Abnormal due to previous vehicular accident. Asymmetric facial

features when smiling, frowning, and puffing up cheeks CN VII damage. No

sensation felt on the left side of the face either blunt or sharp. He has inability to

swallow. He has no blink reflex on left side of eyes. Pupils have no constriction to

light on left side of the eyes they do not constrict; eyes do not converge. NGT

was inserted on right nose. Has decayed teeth, unable to protrude tongue and

move from side to side. Dysarthria and expressive aphasia is present. Upon

auscultation, crackles were heard. Abdomen was round and 2-3 bowel sounds

heard in 1 mins. He has inability to move the right arm and shrug the shoulders.

On upper extremities, muscle strength is 0/5 on right. On lower extremities,

inability to move the right leg and inability to stand is present. Muscle strength on

right side is 0/5, with grade 1 bipedal edema and a positive Babinski reflex.

VI. LABORATORY / DIAGNOSTIC EXAM RESULTS

Date: January 20, 2013HEMATOLOGY

Laboratory Exam Normal Values Result AnalysisComplete Blood Count

WBC 5-11 10^3/uL 13.66 Increased due to

infiltration of inflammatory cells

RBC 4.6- 6.2 10^6/uL 4.50 Decreased due to insufficient oxygen

Hemoglobin 13.5- 18 g/dL 14.5 NormalHematocrit 40-45 % 40.3 NormalMCV 80-100 fL 89.6 NormalMCH 27- 33 pg 32.2 NormalMCHC 31-36 g/dL 36 NormalRDW-CV 11-16% 14.0 NormalRDW-SD 37-54 fL 45.9 NormalPlatelet 150-400 10^3/uL 543 Increased which

causes excessive blood clotting that leads to stroke

Neutrophil 0.55-0.77 0.67 NormalLymphocytes 0.27-0.33 0.18 NormalMonocyte 0-0.12 0.10 NormalEosinophil 0-0.07 0.05 NormalBasophil 0.01-0.05 0.00 Decreased due to

infiltration of inflammatory cells

Date: January 28, 2013

HEMATOLOGYLaboratory Exam Normal Values Result AnalysisComplete Blood CountWBC 5-11 10^3/uL 9.89 NormalRBC 4.6- 6.2 10^6/uL 4.23 Due to decrease

absorption of nutrients such as iron.

Hemoglobin 13.5- 18 g/dL 13.3 Decreased due to insufficient oxygen

Hematocrit 40-45 % 38.3 Decreased due to impaired cerebral blood flow

MCV 80-100 fL 90.5 NormalMCH 27- 33 pg 31.4 NormalMCHC 31-36 g/dL 34.7 NormalPlatelet 150-400 10^3/uL 415 Increased due to

excessive blood clotting that leads to stroke

Neutrophil 0.55-0.77 0.69 NormalLymphocytes 0.27-0.33 0.17 NormalMonocyte 0-0.12 0.05 NormalEosinophil 0-0.07 0.05 NormalBasophil 0.01-0.05 0.09 Increased due to

condition that cause inflammation

Date: January 20, 2013 HEMATOLOGY

Laboratory Exam Normal Values Result AnalysisBlood Chemistry

Creatinine 0.80- 1.50mg/dL 0.9 NormalSerum Electrolytes

Sodium 137-145 mmol/L 135.8 Decrease due to dilutional hyponatremia or fluid retention.

Potassium 3.5- 5.10 mEq/L 5.3 Increased due to counteracting effects of decrease Na.

Blood CoagulationProthrombin TimePatient 9-13 sec 14.8 Increased which

causes blood clotting.

Control 10.3-13.1 sec 10.6 NormalPlatelet 150-400 10^3/uL 543 Increased which

causes blood clotting

Date: January 21, 2013Blood Chemistry

Laboratory Exam Normal Values Result AnalysisBlood Uric acid 0.21-0.50 mmol/L 0.27 NormalFBS 75-110mg/dL 86.9 NormalTriglycerides 0-150mg/dL 75.3 NormalHDL 40-60 mg/dL 33.6 Decreased may

accelerate the development of atherosclerosis because of impaired reverse cholesterol transport and possibly because of absence of other protective effects of HDL.

LDL 0-150 mg/dL 54 Normal

Date: January 28, 2013 HEMATOLOGY

Laboratory Exam Normal Values Result AnalysisBlood ChemistryCreatinine 70.72-132.60

umol/L61.88 Decreased due to

energy failure and aging.

Serum ElectrolytesSodium 137-145 mmol/L 135.8 Decreased due to

diuretics

(Mannitol) given. Potassium 3.5- 5.10 mEq/L 5.00 Normal

Blood CoagulationProthrombin TimePatient 9-13 sec 14.8 Increased which

causes blood clotting.

Control 10.3-13.1 sec 10.6 NormalPlatelet 150-400 10^3/uL 543 Increased which

causes blood clotting

Date: January 20, 2013ABG with Oxygen

Normal Values Result AnalysispH 7.35-7.45 7.46 AlkalinepCO2 35-45 36 NormalpO2 80-90mmHg 136 Adequate oxygen HCO3 22-26 27 AlkalineB.E(B) (-2)-(+2) % 2 NormalO2 Sat 95 % or greater 99% NormalInterpretation:Uncompensated/ simple metabolic alkalosis with adequate oxygenation

Date: January 23, 2013Urinalysis

Laboratory Exam Normal Values Result Significance

Color

Transparency

WBC

RBC

Bacteria

Epithelial Cells

Cast

Glucose

pH

protein

Specific Gravity

Light Yellow

Clear to hazy

0-3/hpf

0-2/hpf

0-50

0-3/hpf

0-3

Negative

6.5-8.0

Negative

1.010-1.025

Light Yellow

Hazy

1/hpf

2/hpf

1

0

0

Negative

7.0

Negative

1.010

Normal

Normal

Normal

Normal

Normal

Normal

Normal

Normal

Normal

Normal

Normal

Diagnostic Examination Result CT Scan Acute Infarct, left frontoparietal lobes

and lentiform nucleus

January 23, 2013Carotid Doppler Ultrasound

1. High resistant waveform pattern on left common carotid artery bulb and internal carotid artery with a low peak systolic velocity indicates a more distal lesion or stenosis2. Irregular Doppler rhythm throughout the study 3. Suggest CTA/MRA of the carotid and vertebrobasilar system (R/O thromboembolism)

ECG ResultJanuary 20, 2013H.R= 65/min (0.916s)PR= 0.202sQRS= 0.094sAxis= 15 degreeQT/ QTC= 0.392s/ 0.408 secRV5= 0.90mvSV1= 0.60 mv

Normal ECG pattern

Date: January 20, 2013Nutritional Risk level: ☐ 0 = Low Risk Level (Level 1) ☐ 1-2 = Moderate Risk Lever (Level 2) ☑ 3 and above = High Risk Level (Level 3)BMI Category: Obese Class IHt.: 5’6” BMI: 28.4Wt.: 80 kg IBW: 62

A B C

SGA Grade ☐0 ☐1 ☑ 2

BMI ☐18.5 – 25 ☑ 25.1 – 30 ☐<18.5 or >30

TLC ☑ >1500 ☐900 < 1500 ☐<900

Total Score = 3

VII. ANATOMY AND PHYSIOLOGY

The nervous system consists of two

major parts: the central nervous system

(CNS), including the brain and spinal

cord, and the peripheral nervous system,

which includes the cranial nerves, spinal

nerves and autonomic nervous system. The function of the nervous system is to

control motor, sensory, autonomic, cognitive, and behavioral activities. The brain

itself contains more than 100 billion cells that link the motor and sensory

pathways, monitor the body’s processes, respond to the internal and external

environment, maintain homeostasis, and direct all psychological, biologic,

physical activity thought complex chemical and electrical messages.

Brain - is the center of the human nervous system and is a highly complex

organ. The brain accounts for approximately 2% of the total body weight; in an

average young adult, the brain weighs approximately 1400 g, whereas 1200 g.

the brain is divided into three major areas: the cerebrum, the brain stem and the

cerebellum. The cerebrum is composed of two hemispheres, the thalamus, the

hypothalamus, and the basal ganglia. The brain stem includes the midbrain,

pons, medulla oblongata. The cerebellum is located under the cerebrum and

behind the brain stem.

Cerebral hemispheres are:

Frontal lobe – is the largest lobe, located in the front of the brain. The major

functions of this lobe are concentration, abstract thought, information storage or

memory and motor function. It contains the Broca’s area, which is located in the

left hemisphere and is critical for motor control speech. The frontal lobe is also

responsible in large part for a person’s affect, judgment, personality, and

inhibitors.

Parietal lobe – a predominantly sensory lobe posterior to frontal lobe. This lobe

analyzes sensory information and relays the interpretation of this information to

other cortical areas and is essential to person’s awareness of body position in

space, size and shape discrimination, and right – left orientation.

Temporal lobe - located inferior to the frontal and parietal lobes, this lobe

contains the auditory receptive areas and plays a role in memory of sound and

understanding of language and music.

Occipital lobe – located posterior to the parietal lobe, this lobe is responsible for

visual interpretation and memory.

The posterior part of the forebrain is the diancephalon, consisting of the

hypothalamus, thalamus, metathalamus, and epithalamus; the subthalamus is

often recognized as a distinct division. Thalamus is a large, dual lobed mass of

grey matter buried under the cerebral cortex. It is involved in sensory perception

and regulation of motor functions. Epithalamus the part of the diencephalon just

superior and posterior to the thalamus, comprising the pineal body and adjacent

structures and Pineal gland is a pine cone shaped gland, connects the

endocrine system with the nervous system in that it converts nerve signals from

the sympathetic system of the peripheral nervous system into hormone signals.

The hypothalamus controls the autonomic nervous system and the secretion of

hormones by the pituitary gland. Through these nerve and hormone channels,

the hypothalamus regulates many vital biological processes, including body

temperature, blood pressure, thirst, hunger, and the sleep-wake cycle.

Brainstem is the region of the brain that connects

the cerebrum with the spinal cord. It consists of

the midbrain, medulla oblongata, and the pons.

Motor and sensory neurons travel through the

brainstem allowing for the relay of signals between

the brain and the spinal cord. The brainstem

coordinates motor control signals sent from the

brain to the body. The brainstem also controls life

supporting autonomic functions of the peripheral nervous system.

Medulla oblongata, also called medulla, the lowest part of the brain and the

lowest portion of the brainstem. The medulla oblongata is connected by the pons

to the midbrain and is continuous posteriorly with the spinal cord, with which it

merges at the opening (foramen magnum) at the base of the skull. The pons

helps in the transferring of messages between various parts of the brain and the

spinal cord. The midbrain is the smallest region of the brain that acts as a sort of

relay station for auditory and visual information. The midbrain controls many

important functions such as the visual and auditory systems as well as eye

movement. Portions of the midbrain called the red nucleus and the substantia

nigra are involved in the control of body movement. The darkly pigmented

substantia nigra contains a large number of dopamine-producing neurons are

located.

Cerebellum (“little brain”) is a structure that is located at the back of the brain,

underlying the occipital and temporal lobes of the cerebral cortex. Although the

cerebellum accounts for approximately 10% of the brain’s volume, it contains

over 50% of the total number of neurons in the brain. It integrates sensory

information to provide smooth coordinated movement. It controls fine movement,

balance and position sense or proprioception.

Sensory Function

The CNS constantly receives large

amounts of sensory input in response to

a variety of stimuli originating both

inside and outside of the body. The

spinal cord and brainstem contain a

number of ascending tracts or pathways

that transmit action potentials from

periphery to various parts of the brain.

The motor system of the brain and

spinal cord is responsible for

maintaining the body’s posture and balance as well as moving the trunk, head,

limb, tongue and eyes; and communicating through facial expressions and

speech. The brain is divided into two hemispheres, called the left and right

hemispheres. Each hemisphere provides a different set of functions, behaviors,

and controls. The right hemisphere is often called the creative side of the brain,

while the left hemisphere is the logical or analytical side of the brain.

Cerebral Circulation: The brain does not store nutrients and requires a constant

supply of oxygen. These needs are met through cerebral circulation; the brain

receives approximately 15% of the cardiac output, or 750 ml per minute of blood

flow. Brain circulation is unique in several aspects. First, arterial and venous

circulation is not parallel as in other organs in the body; this is due in part to the

role the venous system plays in CSF absorption. Second, the brain has collateral

circulation through the circle of Willis, allowing blood flow to the redirected on

demand. Third, blood vessels in the brain have two rather than three layers,

which may make them more prone to rupture when weakened or under pressure.

Arteries blood supply to the brain originates from the common carotid artery, the

first bifurcation off the aorta. The internal carotid arteries arise at the bifurcation

of the common carotid and supply much of the anterior circulation of the brain.

Branches of the internal carotid arteries, anterior and middle cerebral arteries,

along with their connections, anterior and posterior communicating arteries, form

the circle of Willis. The vertebral arteries branch from the subclavian arteries to

supply most of the posterior circulation of the brain. At the level of the brain stem,

the vertebral arteries join to form the basilar artery. The basilar artery divides to

form the two branches of the posterior cerebral arteries. Functionally, the

posterior portion of the circulation and the anterior or carotid circulation usually

remain separate. However, the circle of Willis can provide collateral circulation if

Sustained hypertensionBP 140/90

Disruption of blood vessel lining

Exposure of underlying collagen

one of the vessels supplying it becomes occluded or its ligated. The bifurcations

along the circle of Willis are frequent sites of aneurysm formation due to vessel

wall weakness. Aneuryms can rupture and cause a hemorrhage stroke.

12 Cranial Nerves

Number Name General Functions

Specific Functions

I Olfactory Sensory SmellII Optic Sensory VisionIII Oculomotor Motor Muscles that move the eye

and lid,IV Trochlear Motor Muscles that move the eyeV Trigeminal Mixed Facial sensationVI Abducens Motor Muscles that move the eyeVII Facial Mixed Facial expression and

muscle movementVIII Acoustic Sensory Hearing and equilibriumIX Glossopharyngeal Mixed Taste, sensation in the

pharynx and tongue.

X Vagus Mixed Muscles of the pharynx, parasympathetic innervation of thoracic and abdominal organs

XI Accessory Motor Sternocleidomastoid and trapezius muscle

XII Hypoglossal Motor Movement of the tongue.

VIII. PATHOPHYSIOLOGY

CEREBROVASCULAR DISEASE

Modifiable Factors Smoking Alcoholism Hypertension Obesity Diet- High Caloric, High Salt

intake Hypertensive

arteriosclerotic CVD

Non- modifiable factors Age-67 Genetics- History

of HPN Gender- Male

Hypertension embarks as the stem of cerebrovascular disease formation

and exacerbation. Age and genetics are non-modifiable factors which have been

linked to play a role in hypertension. Whereas non-modifiable factors such as

smoking, obesity and diet, and alcoholism were theoretically believed to damage

blood vessel lining thereby causing unusual changes in blood pressure. The later

together with the additional modifiable factors such as hypertensive

atherosclerotic cerebrovascular disease and cardioembolism magnified the

patient’s predisposition to cerebrovascular infarction.

A person who has a history of smoking has a higher rate of acquiring

cerebrovascular disease. Smoking has chemicals causing the disruption of blood

vessel linings. High caloric diet as well, triggers the stiffening or inflexibility of the

CN III - No pupil reaction to light (left eye) CN III & IV - Impaired accommodation CN V - Analgesia (left side of face)

No blink reflex (left eye) CN VII - Asymmetric facial facial features CN IX & XII - Unable to move tongue CN X - Dysphagia

CN X - Dysarthria Expressive aphasia CN XI - Unable to shrug shoulders (+) Babinski Dizziness Severe headache Cerebral contralateral paralysis

blood vessels which make them more susceptible to hypertension induced

ischemia or infarction.

The hardening and roughening of the vessel walls together with the

presence of cardioemboli increases the possibility of tearing in sustained

hypertension episodes.

Likewise, the distortion from a normal endothelium may also occur in a

manner that is thought to be beneficial for the body – that is the healing process

initiated by platelets and other clotting factors.

During hypertension episodes, tearing of the endothelium is inevitable

which exposes the underlying collagen. This event leads to the activation of the

clotting factor and platelet aggregation to initiate restoration. However, the

repairing process is not always complete and perfect. This permanently changes

the architecture of the blood vessels making it narrow, stiff, uneven and more

vulnerable to adhesions and further fluctuations in blood pressure.

Due to narrowed blood vessel in the brain, embolus clogged and further

resulted to poor blood circulation to the more distal portion of blood vessels. The

sudden drop in blood pressure caused the antagonistic effect on the patient.

In ischemia, blood flow to focal regions of the brain is impaired.

Due to increased length of inadequate supply of oxygen to portions

affected by the ischemia, infarction resulted.

IX. NURSING CARE PLANDATE: JANUARY 28, 2013 TIME: 10:00 AM

Assessment Nursing Diagnosis

Scientific Explanation Planning Intervention Rationale Evaluation

Subjective:- “Hindi na sya nakakagalaw sa higaan nya”, as verbalized by the relative.

Objective:- Inability to assume side lying or pronation.- Obesity with weight = 80kg-BMI: 28.4- Motor strength =0/5 on right

Impaired physical mobility related to hemiparesis of the right side of the body

A stroke is a condition in which the brain cells suddenly die because of a lack of oxygen. This can be caused by an obstruction in the blood flow, or the rupture of an artery that feeds the brain. The patient may suddenly lose the ability to speak, there may be memory problems, or one side of the body can become paralyzed.

(www.medicalnewstoday.com)

Short Term : - After 1 hour of nursing intervention, the patient will be able to change position regularly with assistance of the relatives.

Long Term: - After series of nursing interventions, the patient with the assistance of the family will be able to improve continuously physical mobility; and be free from ulcerations, contractures and pain.

Independent Intervention:- Discussed the importance of mobility.

- Taught regarding the possible risk for ulcerations and contractures.

- Assisted the patient and the relatives in changing position to left side.

- Put pillows on patient’s back, in between legs and below the bony prominences.

- Advised relatives to change position slowly if possible

- Promotes understanding of repositioning.

- Enhance the understanding about the risks of impaired physical mobility.

- To prevent pressure ulcers.

- Provides support to position and prevents ulcers from developing.

- Promotes continuity of care.

Short term: - After 1 hour of nursing intervention, the patient was able to change position regularly with assistance of the relatives.Long Term:-After series of nursing interventions, the patient with the assistance of the family was able to improve continuously physical mobility; and be free from ulcerations,

or at least every 2 hours.

- Demonstrated passive ROM to all limbs and joints.

-Encouraged the patient to exercise joints on left hemisphere and the relatives to perform passive and active ROM on the right hemisphere.

Interdependent Nursing Intervention:- Assist in physical therapy program (whenever ordered by the physician).

- Promotes circulation, muscle tone, joint flexibility, and prevents contractures and weakness.

- To maintain joint mobility, regain motor control; prevent contractures in the paralyzed extremity.

- Promotes problem-focused approach to healing.

contractures and pain.

DATE: January 28, 2013 TIME: 10:00 AM

Assessment Data Nursing Diagnosis

Scientific Explanation

Planning Intervention Rationale Expected Outcome

Subjective Data:“Di naming maintindihan ang sinasabi ng pasyente” as verbalized by the relatives.Objective Data:- Right facial paralysis - Muscle and facial tension- Speaks/verbalizes with difficulty; stuttering; slurring- Difficulty forming words or sentences- Absence of eye contact

Impaired Verbal Communication related to damage of CN IX, X and XII.

Decreased, delayed, orabsent ability to receive, process,transmit, and/or use a system ofsymbols may be caused by a decrease in circulation to brain and loss offacial/oral muscle tone/control;generalized weakness/fatigue

Short Term:After 8 hours of nursing intervention, the patient will be able to establish a method of communication in which needs can be expressed.

Long Term:After series of nursing interventions, the patient will be able to establish communication and relate to his environment progressively.

Independent Intervention:- Provided alternative methods of communication, like pictures, or visual cues, gestures and demonstration.

- Talked directly to patient. Speaking slowly and directly.

- Used yes or no question to begin.

- Spoke in normal tones and avoid talking too much. Give patient ample time to respond.

- Provides communication of needs/ desires based on individual situation/underlying deficit.

- Enhances clear understanding and decreases anxiety.

- Reduces anxiety and confusion on having to respond with large amount of data.

- Patient is not necessarily hearing impaired and raising voice may irritate or anger patient.

After 8 hours of nursing intervention, the patient was able to establish a method of communication through tapping of left index and middle finger which corresponds to a ‘yes’ and ‘no’ answer respectively.

- Encouraged family members and visitors to communicate with patient.

- Anticipated and provide patient’s needs.

Interdependent Nursing Intervention:- Assist in speech therapy program (whenever ordered by the physician).

- To reduce patient’s isolation, promote establishment of effective communication, and maintain sense of connectedness with family.

- Helpful in decreasing frustration when dependent on others.

- Promotes problem-focused approach to healing.

DATE: JANUARY 28, 2013 TIME: 10:00 AM

Assessment Nursing Diagnosis

Scientific Explanation

Planning Interventions Rationale Evaluation

Subjective: “Medyo nahihirapan pa siyang huminga”, as verbalized by the relative.

Objective: Crackles heard Dyspnea Productive

cough Vital signs:

BP-T-PR-RR-

Ineffective airway clearance related to ineffective cough and retained secretions.

The inflammatory response to infection causes tissue edema and exudates formation in the lungs, the inflammatory response can narrow and potentially obstruct passages and alveoli

Ref. Medical- Surgical Nursing Critical Thinking for Collaborative Care, col.1, 5th edition, Ignatius, et.al. page978

After 4 hours of nursing interventions, the client will be able to maintain airway patency.

Monitored vital signs especially the RR.

Auscultated the lung sounds, noting areas of decreased ventilation and presence of adventitious sounds.

Encouraged to increase fluid intake.

Advised the relatives to elevate the head of the bed at least 30 degrees.

To obtain baseline data.

Bronchial lung sounds are commonly heard over areas of lung density or consolidation.

Hydration helps decrease the viscosity of secretions, facilitating expectorations.

Positioning facilitates chest expansion and respiratory efficiency.

Relaxes bronchial and uterine smooth muscle.

After 4 hours of nursing interventions, the client maintained airway patency as evidenced by expectorating clear secretions readily.

Assisted on nebulizer treatment.

X. DRUG STUDY

Name of drugs

Classification and

Mechanism of Action

Indication Contraindication Side effects Nursing ResponsibilitiesMonitoring Parameters

Generic Name:Digoxin

Brand Name:Lanoxin

Dose: 0. 25 mcg (1/2 tab)Route: oralFrequency: every other day

> Cardiac Glycosides>Inhibits sodium-potassium- activated adenosine triphosphatase, promoting movement of calcium from extracellular to intracellular cytoplasm and strengthening myocardial contraction. Also acts on CNS to enhance vagal tone, slowing

>Atrial fibrillation and flutter

>Hypersensitivity to drug and to those with digitalis-induced toxicity, ventricular fibrillation, or ventricular tachycardia unless caused by heart failure>Use with extreme caution in elderly patients and in those with acute MI, incomplete AV block, sinus bradycardia, PVC’s, chronic constrictive pericarditis, hypertrophic cardiomyopathy, renal insufficiency,

CNS: agitation, fatigue, generalized muscle weakness, hallucinations, dizziness, headache, malaise, paresthesia, stupor, vertigo.CV: arrthymias, heart block EENT: blurred vision, diplopia, light flashes, photophobia, yellow-green halos around visual imagesGI: anorexia,

>Before giving loading dose, obtain baseline data (heart rate, rhythm, blood pressure and electrolytes) and ask patient about use of cardiac glycosides within the previous 2-3 weeks. > Monitor digoxin level carefully. Take corrective action before hypokalemia occurs. Hyperkalemia may result from digoxin toxicity. > Excessively slow pulse rate may be a sign of digitalis toxicity. Withhold drug and notify prescriber. > Instruct patient to report adverse reactions promptly, nausea, vomiting, diarrhea, appetite loss, and visual disturbances these may be

>Monitor vital signs (esp. pulse rate), potassium and digoxin level >May prolong PR interval or depress ST segment.

conduction through the SA and AV nodes.

severe pulmonary disease, or hypothyroidism.

nausea, diarrhea, vomiting

indicators of toxicity. >Encourage patient to eat a consistent amount of potassium-rich foods.

Name of drugs

Classification and Mechanism of Action

Indication Contraindication Side effectsNursing Responsibilities

Monitoring Parameters

BRAND NAME:AldactoneGENERIC NAME:Spironolactone DOSE:Tablet 50mgFREQUENCY:BidROUTE:oral

Antagonist aldosterone in the distal tubules,increasing sodium and water excretion.

Management of essential hypertension, manangement of edematous conditions in CHF, treatment of hypokalemia,

Acute renal insufficiency, anuria, hyperkalemia

Gynecomastia, agranulocytosis, headache, drowsiness, lethargy, GI disturbances, inability to achieve or maintain erection, irregular menses, amenorrhea, ataxia, post-menopausal bleeding, drug fever.

1)Obtain patient history,including drug history and any known hypersensitivity2)Assess fluid volume status:intake and outputratios and record,count or weigh diapers as appropriate,weight,distended red veins, cracklesin lung,color,quality, and specific gravity of urine,skin turgor, adequacy of pulses,moist mucus

1)Monitor manifestations of hyperkalemia:MS:fatigue. muscle weakness;CV:arrythmias,hypotension,NEURO:paresthesias,confusion,RESP:dyspnea2)Monitor for manifestations of hyponatermia:CV:B\P,cold,clammy skin, hypo- or hypervolemia;GI:anorexia,nausea,vomiting,diarrhea,abdominal cramps:NEURO:lethargy, inceased ICP,confusion,headache,siezures,coma,fatigue,tremor,hyperreflexia.3)Monitor for manifestations of hyperchloremia:NEURO:weakness,lethargy,coma;RESP:deep rapid breathing4)Monitor

membranes should be reported.

electrolytes:potassium,sodium,calcium,magnesium;also include BUN,ABGs, uric acid, CBC,blood glucose.

Name of Drugs

Classification and Mechanism of

Action

Indication Side Effects Contraindication Nursing Responsibilities

Monitoring Parameters

Brand Name: Dolcet

Generic Name: Tramadol

Dose: 1 tabFreq: TIDRoute: PRN

Analgesics

It may bind to mu- opioid receptors and inhibit reuptake of norepinephrine and serotonin.

Management of moderate to severe pain

CNS & GI disturbances:Nausea, dizziness, somnolence, asthenia, fatigue, hot flushes, constipation, diarrhea, flatulence, dry mouth, pruritus, increased sweating, tinnitus.

Acute intoxication w/ alcohol, hypnotics, narcotics, centrally-acting analgesics, opioids or psychotropic drugs. Hypersensitivity.

>Assess for location, onset and characteristics of pain. Use a pain- rating scale to rate pain.>Monitor vital signs and assess for orthostatic hypotension or signs of CNS depression.>Discontinue drug and notify the physician if signs and symptoms of hypersensitivity occur.>Assess bowel and bladder function, report urinary frequency or retention.>May be taken with or without food.

Monitor vital signs, I&O, liver and renal function studies.

Name of Drug

Classification and Mechanism

of Action

Indications Side Effects Contraindications Nursing Responsibilities

Monitoring Responsibilitie

s

Brand Name: Colchicine

Generic Name: Colcrys

Dose:800 mg/ tabFreq:TIDRoute: oral

Antigout drug

It may reduce the crystal- induced inflammation by reducing lactic acid production by leukocytes by inhibiting leukocyte migration and by reducing phagocytosis.

For the prophylaxis and the treatment of acute gout flares

CNS: Fatigue, headache, peripheral neuritis, sensory motor neuropathy

Dermatologic: alopecia, macula papular rash, purpura, rash

GI: Diarrhea, nausea, vomiting, abdominal cramping, abdominal pain, lactose intolerance

Serious GI, hepatic, cardiac, or renal disorders. Use in presence of combined renal and hepatic disease.

>Document joint involvement, noting pain, swelling and degree of mobility.>Take the medication on an empty stomach and it should be taken for at first sign of gout attack.>Teach client to report an increase or decrease in discomfort and swelling.>Instruct client to report nausea and vomiting or diarrhea.

Monitor for alters liver function tests, increase alkaline phosphates, AST, decrease thrombocyte values and false positive for Hgb or RBC in urine

Name of Drug Classification and Mechanism of Action

Indication Side effects Contraindications Nursing Responsibilities

Monitoring Parameters

Brand Name:Zertin

Generic name:Erdosteine

Dose:1cap

Route:Oral

Frequency:BID

Classification:Mucolytic Agents

Mechanism of Actions:Acts as a pro drug and its metabolites are mainly responsible for mucolytic activity, due to the presence of free thiol groups which cause the splitting up of the intra- and intermolecular disulfide bridges of several proteins and mucoproteins present in the expectoration, resulting in a reduction of the mucus elasticity and viscosity.

Treatment of patients with acute and chronic bronchopulmonary diseases, rhinosinusitis, laryngopharyngitis or exacerbations of these chronic diseases in association with mucus production and transport.

GI side effects:

Gastric burning, Nausea Diarrheaageusia dysgeusia

Hypersensitivity to erdosteine

Hepatic disorders and abnormalities

Renal insufficiency

Homocystinuria

Phenylketonuria

Record the characteristics of cough and bronchial secretions before starting the therapy.

Obtain and record baseline vital signs.

Observe for and record any gastrointestinal symptoms before starting therapy.

Name of Drug Classification Indications Contraindications Side Effects Nursing Considerations

Monitoring Parameters

Generic Name:Carbamazepine

Brand Name:Zynapse

Dose: 3mlRoute: OralFreq: BID

Anticonvulsant

Mechanism of Action:- Carbamazepine reduces polysynaptic responses and blocks post-tetanic potentiation. It is effective in partial and generalised convulsions as well as in mixed types but not in petit mal seizures. It reduces or abolishes pain in trigeminal and glossopharyngeal neuralgia.

Trigeminal and glossopharyngeal neuralgia, cerebrovascular diseases, in acute recovery phase, in signs & symptoms of cerebrovascular insufficiency & in cranial traumatism, epilepsy

Hypersensitivity, severe hemic disorders, severe bradycardia (<50beats/min), history of bone marrow depression, history of intermittent porphyria. (Pregnancy, lactation).

Dizziness, drowsiness, ataxia; dry mouth, abdominal pain, nausea, vomiting, anorexia; leucopenia, proteinuria, renal failure, heart failure and hyponatraemia.

Potentially Fatal: Agranulocytosis, aplastic anaemia, hepatic failure, severe exfoliative dermatitis and Stevens-Johnson syndrome.

- Check cardiac rate before administration.- Take with or between meals.- Avoid grapefruit juice.- Skin test.- Take history of blood disorders and other related disorders.

- Cardiac rate- GI discomfort- LOC- Inspect mouth regularly

Name of Drug Classification and Mechanism of Action

Indication Side effects Contraindications Nursing Responsibilities

Monitoring Paremeters

Brand Name:OsmotrilGeneric name:MannitolDose:80ccRoute:IVFrequency: Every 8 hours

Classification:Diuretic

Mechanism of Actions:

Increases the osmotic pressure of glomerular filtrate, which inhibits tubular reabsorption of water and electrolytes and increases urinary output.

Used for the promotion of diuresis before irreversible renal failure becomes established, the reduction of intracranial pressure, the treatment of cerebral edema, and the promotion of urinary excretion of toxic substances.

Dizziness

Headache

Rebound increased ICP

Confusion

Seizures

Fever

Dry Mouth

Hypersensitivity

Severe renal disease

Severe dehydration

Pulmonary congestion

Severe pulmonary edema

>Assess patient’s condition before therapy and regularly thereafter to monitor drug effectiveness.>Assess neurologic status if drug is given for increased ICP:LOC,ICP reading ,pupil size and reaction.>Assess patient for tinnitus, hearing loss and ear pain.>Assess B/P before and during therapy w/ patient lying, standing and sitting, orthosthatic hypotension can occur rapidly.

Monitor a) Serum electrolytes, osmolality

b) BUN, serum creatinine

c) Urine output

d) Central venous pressure, if possible

e) Lung auscultation

Name of the Drug

Classification/ Mechanism of Action

Indication Contraindication Adverse Reaction Nursing Management

Monitoring Parameter

Generic Name:Omeprazole

Brand Name:Omepron

Dosage:40 mg/cap

Route:Oral

Frequency:OD

Antisecretory drug; Proton pump inhibitor

Gastric acid-pump inhibitor: Suppresses gastric acid secretion by specific inhibition of the hydrogen-potassium ATPase enzyme system at the secretory surface of the gastricparietal cells; blocks the final step of acid production.

Indicated for:•Short-term treatment of activeduodenal ulcer;First-line therapy intreatment of heartburn orsymptoms of gastroesophageal refluxdisease (GERD);•Short-term treatment of active benign gastric ulcer;•GERD, severe erosiveesophagitis, poorlyresponsive symptomaticGERD;•Long-term therapy:Treatment of pathologichypersecretory conditions(Zollinger-Ellisonsyndrome, multipleadenomas, systemicmastocytosis);•Eradication of H. pyloriwith amoxicillin ormetronidazole andclarithromycin;

Contraindicated with hypersensitivity to omeprazole or its components; Use cautiously with pregnancy, lactation

CNS: Headache, dizziness, asthenia, vertigo, insomnia, apathy, anxiety, paresthesias, dream abnormalities

Dermatologic:Rash, inflammation, urticaria, pruritus, alopecia, dry skin

GI: Diarrhea, abdominal pain, nausea, vomiting, constipation, dry mouth, tongue atrophy

Respirator: URTI symptoms, cough, epistaxis

•Take the drug before meals.•Report severe headache, worsening of symptoms, fever, chills.•Swallow the capsules whole; do not chew, open, or crush them.

Periodic Liver Function test.

Name of the Drug Classification/ Mechanism of Action

Indication Contraindication Adverse Reaction Nursing Management

Monitoring Parameter

Brand Name: Aprovel

Generic Name: Irbesartan

Dosage:300mg

Route:Oral

Frequency:OD

Antihypertensive

Mechanism of Action: Inhibits the vasoconstricting and aldosterone-secreting effects of angiotensin II by selectively blocking binding of angiotensin Ii to receptor sites in many tissues. Therapeutic Effect: Lowers blood pressure.

For the treatment of hypertension & treatment of renal disease in patients with hypertension and type II diabetes mellitus, as part of an antihypertensive drug regimen.

Hypersensitivity to irbesartan.

CNS: fatigue, anxiety, dizziness, headache.

CV: chest pain, edema, tachycardia.

EENT: pharyngitis, rhinitis, sinus abnormality.

GI: UTI.

Metabolic: hyperkalemia.

Musculoskeletal: musculoskeletal trauma or pain.

Respiratory: URTI.

Skin: rashes.

•Monitor patient’s BP regularly.•Monitor patient’s electrolytes.•Assess patient’s and family’s knowledge of drug therapy.•Give with a diuretic if drug is needed to control blood pressure.•Place in supine position and give an IV infusion of NSS if patient becomes hypotensive.•Tell patient that drug may be taken once daily with or without food.•Instruct client to avoid driving and hazardous activities until CNS effects of drug are known.

Periodic liver and kidney function test.

Drug Name Classification and Mechanism of Action

Indication Side Effects Contraindications

Nursing Responsibilities

Monitoring Parameters

Generic name:

Levofloxacin

Brand name:

Levox

Dosage:

500mg

Route: IV

Frequency:

OD

ANTIBIOTICS

-inhibits bacterial DNA gyrase and prevents DNA replication, transcription, repair and recombination in susceptible bacteria

-infections caused by susceptible strains of microorganism

-acute bacterial exacerbation

-CAP

-nosocomial pneumonia

CNS: seizures, encephalopathy, dizziness, headache, insomnia, painCV: chest pain, palpitations, vasodilationGI: abdominal pain, nausea, constipation, diarrhea, vomitingRESPI: allergic pneumonitis, dyspneaMUSCULO: back pain, tendon rupture.SKIN: photosensitivity, pruritus, rash

With allergy to floroquinolones

Use cautiously in patients with history of seizure disorder or CNS diseases

>If patient experiences symptoms of excessive CNS stimulation (restlessness, hallucinations, tremor, confusion) stop drug and notify prescriber. >Advise px to take the drug with plenty of fluids and to space antacids, sucralfate, and products containing iron and zinc.> Tell px to take oral soln 1 hour before or 2 hrs after eating>Advise px to avoid excessive sunlight, use sunscreen and wear protective clothing when outdoors. >Advice client to report sore throat, bruising, joint pain, furry tongue, loose stools or diarrhea

Assess renal function

Assess bowel patterns

Monitor glucose level

May increase eosinophil count. May decrease WBC count.

Name of Drug

Brand Name:

Norvasc

Generic Name:

Amlodipine

Dose: 5mg

Route: oral

Freq: 1 tab

Classification and Mechanism of action

>calcium channel blocker

Inhibits the movement of calcium ions across the membranes of cardiac and arterial muscle cells; inhibits transmembrane calcium flow, which results in the depression of impulse formation in specialized cardiac pacemaker cells, slowing of the velocity of conduction of the cardiac impulse, depression of myocardial contractility, and dilation of coronary arteries and arterioles and peripheral arterioles; these effects lead to decreased cardiac work, decreased cardiac oxygen consumption, and in patients with vasospastic (Prinzmetal's) angina, increased delivery of oxygen to cardiac cells.

Indication

Amlodipine is indicated for the treatment of hypertension, chronic stable angina and confirmed or suspected vasospastic angina. 

Side Effects

CNS: dizziness; - dizziness or lightheadedness; - drowsiness; - excessive tiredness; - fainting; - fainting; - flushing (feeling of warmth); - headache; CV- more frequent or more severe chest pain; - rapid heartbeat; - rapid, pounding, or irregular heartbeat; GI- stomach pain; - upset stomach;SKIN- swelling of the hands, feet,

Contraindication

NORVASC is contraindicated in patients with known sensitivity to amlodipine.

Nursing Responsiblities

Report significant swelling of face or extremities.

Take care to have support when standing & walking due to possible dose-related light-headedness/dizziness.

Report shortness of breath, palpitations, irregular heartbeat, nausea, or constipation to physician.

Can administer with or without food

Caution patient to continue taking drug even when he feels better.

Monitoring Parameters

Monitor BP for therapeutic effectiveness. BP reduction is greatest after peak levels of amlodipine are achieved 6–9 h following oral doses.

Monitor for S&S of dose-related peripheral or facial edema that may not be accompanied by weight gain; rarely, severe edema may cause discontinuatio

ankles, or lower legs; 

n of drug. Monitor BP

with postural changes. Report postural hypotension. Monitor more frequently when additional antihypertensives or diuretics are added.

Monitor heart rate; 

NAME OF DRUG

CLASSIFICATION AND

MECHANISM OF ACTION

INDICATION ADVERSE EFFECTS

CONTRAINDICATION NURSING RESPONSIBILITIE

S

MONITORING PARAMETERS

GENERIC NAME:Metoclopramide

BRAND NAME:Reglan

ROUTE: Oral

FREQUENCY: q8o

DOSAGE:1/2 tab, 5mg.

Prokinetic agent ( GI stimulant)

Blocks dopamine receptors in chemoreceptor trigger zone of the CNS. Stimulates motility of the upper GI tract and accelerates gastric emptying

To facilitate intubation of small bowel; symptomatic treatment of gastroesophageal reflux

CNS:restlessness,drowsiness,fatigue,insomia,dizziness,anxiety

CV:tansient hypertension

GI:nausea and diarrhea

Sensitivity or intolerance to metoclopramide; allergy to sulfiting agents; history of seizure disorders

>Report immediately the onset of restlessness, involuntary movements, facial grimacing, rigidity, or tremors.>Avoid alcohol and other CNS depressants.>Report S&S of acute dystonia, such as trembling hands and facial grimacing, immediately.

Monitor serum aldosterone it may be elevated

Monitor the adverse  reactions associated with increased serum prolactin concentration

Monitor for possible hypernatremia and hypokalemia, especially if patient has CHF or cirrhosis.

NAME OF DRUG

CLASSIFICATION AND MECHANISM OF ACTION

INDICATION ADVERSE EFFECTS

CONTRAINDICATION NURSING RESPONSIBILITIES

MONITORING PARAMETERS

GENERIC NAME:Lactulose

BRAND NAME:Duphalac

Route: oralFreq: ODDose: 30mL

Laxative

Lactulose promotes peristalsis by producing an osmotic effect in the colon with resultant distention. In hepatic encephalopathy, it reduces absorption of ammonium ions and toxic nitrogenous compounds, resulting in reduced blood ammonia concentrations it also Inhibits bacterial DNA gyrase thus preventing replication insusceptible bacteria.

Use to treat constipation

GI: Abdominal discomfort associated with flatulence and intestinal cramps, Nausea , vomiting and diarrhea

Contraindicated on patients with

>low- galactose diet

>diabetes mellitus

>Assess condition before therapy and reassess regularly thereafter, to monitor drug effectiveness

>Monitor patient for any adverse GI reactions such as nausea, vomiting and diarrhea

>Mix with fruit juice, water, or milk to make oral solution more palatable.

>Instruct patient not to take other laxatives while receiving lactulose therapy

Monitor sodium level for hypernatremia

Monitor potassium level

Name of Drug

Classification & Mechanism of Action

Indication Contraindication Adverse Effects

Nursing Responsibilities

Monitoring Parameters

Generic Name: - Salbutamol

Brand Name:- Duavent

Dosage: 1-2 inhalation single dose.Frequency:q 8o

Route: neb

- Adrenergic Inhalants/Bronchodilator- Stimulates beta – 2 receptorsof bronchioles by increasing levels of cAMP which relaxes smooth muscles to produce bronchodilation.

- Management of reversible bronchospasm associated with obstructive airway disease (eg. Bronchial asthma) ; COPD

- Hypersensitivity to salbutamol also to atropine and its derivatives.

- CNS: Fine skeletal muscle tremor, leg cramps, - CARDIO: palpitations, tachycardia, hypertension, headache, hypotension, peripheral vasodilatation, flushing, feeling of tension or nervousness- GI: nausea, vomiting, dizziness, hyperactivity

- Give oral administration with meals to decrease gastric irritation- Instruct patient on dosage and not to use more than prescribed. - Teach patient to use inhaler- Instruct to limit caffeine products such as chocolates, coffee and tea.- Observe for paradoxical bronchospasm (Wheezing). If Condition occurs, with hold medication and notify physician or other healthcare professional immediately

- Monitor vital signs especially heart rate

XI. PROGNOSIS

Patient was admitted last January 20, 2013 with a chief complaint of difficulty

waking up and a right sided body weakness. He underwent several laboratory

and diagnostics examinations at Mary Mediatrics Medical Center such as

Hematology, Blood Chemistry, Arterial Blood Gas and diagnostics such as

Cranial Tomography Scan, and Carotid Doppler Studies for thorough verification

and diagnosis of the disease.

He had consistent Glasgow Coma Scale of 12 and he was given medication

which includes Zertin, Mannitol, Approvel, Zynapse, Lactulose, Omeprazole,

Approvel, Lanoxin, Lactulose, Amlodipine, Dolcet, Levofloxacin, and Combivent.

Patient was discharged last February 2, 2013 and is currently undergoing

physical therapy and speech therapy to support motor development and verbal

communication. Care and safety measures were provided. In consideration to the

management given together with the response of the patient to the therapeutic

procedures, the patient’s prognosis is fair.

XII. DISCHARGE PLANNING / HEALTH TEACHING

Encouraged the patient to promote a healthy lifestyle through maintaining a weight appropriate for height and age, following a healthy diet (including modest alcohol consumption) and daily exercise (about 3 to 5 times per week for 30 to 60 minutes.

Advised the client to stay in a well-ventilated and quiet environment to minimize stress.

Advised the client to manage stress. Do 20 minutes of relaxation per day. Advised the client to adhere to the treatment prescribed by the physician.

Compliance is a must. Informed the patient for DASH diet (Dietary Approach to Stop

Hypertension). The dash diet is high in fruits and vegetables, moderate in low fat dairy products and low in animal protein (has a substantial amount of plant protein from legumes and nuts)

Advised the client to be patient because we all know that recovery from stroke takes time and patience.

Encouraged the family to talk to the patient frequently to keep him from feeling sad and alone.

Instructed the family to monitor blood pressure regularly, monitor blood sugar levels, and keep it in a healthy range and to prevent the accumulation of bad cholesterol.

Advised the patient to immediately report the following symptoms/ and instructed the family to bring the patient to the nearest hospital as early as possible if these symptoms arise:

1. Weakness: Sudden weakness, numbness and/or tingling in the face, arm or leg

2. Visual problems: Sudden loss of vision, especially in one eye or  double vision

3. Trouble Speaking: Temporary loss of speech, or trouble understanding  speech

4. Headaches: Sudden, severe and unusual headaches5. Dizziness:

Sudden unsteadiness especially with any of the above signs Advised the client to attend mass every Sunday and have faith to our

Creator. Instructed the family to help/ assist the client in performing activities of

daily living. Return to OPD as advised by the physician

XIII. ACKNOWLEDGEMENT

In completing this case study, the members of this group encountered

many individuals who helped by offering their time, knowledge and skills. The

group would like to give our deepest gratitude to these individuals

First and foremost to our creator Almighty God, for the gift of life and

wisdom, for lending us time to do our task and for always giving us strength in

completing this whole heartedly with such eagerness and passion.

To our parents, family and friends, for their unconditional love, for their

emotional and financial support and for their endless understanding throughout

the accomplishment of the presentation.

To the chief nurse and staff of Mary Mediatrix Medical Center who

welcome us and assisted us throughout our stay in the hospital.

To our patient, for letting us know necessary information in completing

our clinical appraisal and allowing the physical assessment to be done.

To our beloved clinical instructors, who have been patient and considerate

in guiding us and sharing to us their knowledge and expertise in nursing, for

understanding our shortcomings and our imperfections as a student and for the

time they spent in providing us all the necessary knowledge we need to know.

XIV. REFERENCES

Smeltzer S.C.,Bare B.G.,Hinkle J.L., Cheever K.H.(2010) Brunner and Suddarht’s Texbook of Medical- Surgical Nursing. Twelfth Edition,1896-1931pp. Wolters Kluwer, Lippincott Williams & Wilkins.

Blum, A. (1998) Role of Lymphocytes in Heart Disease Retrieved January 20, 2013 from http://www.circulationcirc.ahajournals.org

Singh, V.N. (2013) Low HDL Cholesterol Hypoalphalipoproteneimia Retrieved January 21,2013 from emedicine.medscape.com/article/127943-overview

Creatinine and Creatinine Clearance Retrieved from: http://www.webmd.com/a-to-z-guides/creatinine-and-creatinine-clearance?page=3

Basophil Retrieved from: http://www.medfriendly.com/basophil.html Wedro, B.(2013) What causes heart murmur, Retrieved from:

http://www.medicinenet.com/heart_murmur/page2.htm Salvador Cruz- Flores (2013) Physical Examination Retrieved from:

http://emedicine.medscape.com/article/1916852-clinical#a0256 What do low creatinine levels mean? Retrieved from:

http://www.netdoctor.co.uk/ate/liverandkidney/203123.html Larsen H. (2010) Importance of Potassium Retrieved from:

http://afibbers.org/resources/potassium.pdf Balana Cynthia, (2010) Stroke afflicts the young, too, says expert 

Philippine Daily Inquirer from http://newsinfo.inquirer.net/inquirerheadlines/nation/view/20101020-298702/Stroke-afflicts-the-young-too-says-expert