LIST OF CONTENTS

introduction

review of

related

literature

anatomy and

physiology

patient’s

health history

physical

assessment

review of system

laboratory data

drug study

pathophysiology

NCP

discharge plan

appendices

INTRODUCTIONCerebrovascular accident is the rapidly developing loss of the brain

functions duet o disturbance in the blood vessels supplying blood to the brain causing brain tissue to die because of lack of nutrients and oxygen. This can be due to ischemia caused by thrombosis or embolism or due to a haemorrhage.

CVA is the third leading cause of death in the United States and the leading cause of adult disability in the world. Three million Americans are currently permanent disabled from stroke. It is estimated that four of every four of every five families in the United states are affected by stroke in their lifetime and more than half a million of people in the United States experience a new or recurrent stroke each year.

Our patient is a government employee and engineer who is a resident of Housing, Brgy. Canlanipa, Suriga0o City. He is a father of a kid and a hard working husband. He is 46 year old living together with his family in a cemented house. But unfortunately, he was confined at Surigao Medical Center last August 11, 2009 and was diagnosed of having Cerebrovascular accident Thrombosis secondary to hypertension.We have choosen this kind of case specially CVA- thrombosis or comonly known as stroke, for it is an interesting and challenging topic to learned. Especially most of us have family history of stroke that’s why we are veruy crios about the cause, symptoms, complications, and how this disease could be treated.

CVA is the third leading cause of death in the United States and the leading cause of adult disability in the world. Three million Americans are currently permanently disabled from stroke. It is estimated that four of every five families in the United States will be affected by stroke in their lifetime and more than half a million people in the United States experience a new or recurrent stroke each yearWorldwide, one-quarter of all strokes are fatal. Stroke kills about 150,000 Americans each year, or almost one out of three stroke victims. The incidence of stroke increases exponentially from 30 years of age, and etiology varies by age. Advanced age is one of the most significant stroke risk factors. 95% of strokes occur in people age 45 and older, and two-thirds of strokes occur in those over the age of 65. However, stroke can occur at any age, including in fetuses. Men are 1.25 times more likely to suffer strokes than women, yet 60% of deaths from stroke occur in women. Since women live longer, they are older on average when they have their strokes and thus more often killed. Some risk factors for stroke apply only to women.

Stroke can affect patients physically, mentally, emotionally, or a combination of the three. The results of stroke vary widely depending on size and location of the lesion. Dysfunctions correspond to areas in the brain that have been damaged.We have chosen this kind of case specifically CVA- thrombosis or commonly known as stroke, for it is an interesting and a challenging topic to be learned. Especially most of us have family history of stroke that’s why we are very curious about the causes, symptoms, complications and how this disease could be treated.Cerebrovascular accident (CVA) is the rapidly developing loss of brain functions due to a disturbance in the blood vessels supplying blood to the brain causing brain tissue to die because of lack of nutrients and oxygen. This can be due to ischemia (lack of blood supply) caused by thrombosis or embolism or due to a hemorrhage.

Worldwide, one quarter of all strokes are fatal. Stroke Worldwide, one quarter of all strokes are fatal. Stroke kills about 150, 000 Amrican each year, or almost one out of kills about 150, 000 Amrican each year, or almost one out of three stroke victims. The incidence of strokes increases three stroke victims. The incidence of strokes increases exponentially from 30 years of age, and etiology varies by age. exponentially from 30 years of age, and etiology varies by age. Advanced age is one of the most significant stroke risk factors. Advanced age is one of the most significant stroke risk factors. 95% of strokes occur in people age 45 and older, and two-thirds 95% of strokes occur in people age 45 and older, and two-thirds of strokes occur in those over the gae of 65. however, stroke of strokes occur in those over the gae of 65. however, stroke can occur at any age, including in fetuses. Men are 1.23 times can occur at any age, including in fetuses. Men are 1.23 times more likely to suffer strokes than women, yet 60 % of deaths more likely to suffer strokes than women, yet 60 % of deaths from stroke occur in women. Since in woman live longer, they from stroke occur in women. Since in woman live longer, they are older on average when they have their strokes and thus are older on average when they have their strokes and thus more often killed. Some risk factors for stroke apply only to more often killed. Some risk factors for stroke apply only to women.women.

Stroke can affect patients physically, mentally, Stroke can affect patients physically, mentally, emotionally, or a combination of the three. The results of emotionally, or a combination of the three. The results of stroke vary widely depending on size and location of the lesion. stroke vary widely depending on size and location of the lesion. Dysfunction correspond to areas in the brain that have been Dysfunction correspond to areas in the brain that have been damage.damage.

REVIEW OF RELATED LITERATURE

The word stroke as a Synonym for apoplectic seizures as early as 1599, and is fairly literal translation of the Greek term. In medicine, a stroke fit, or faint is sometimes referred to us an ictus (cerebri) from the Latin icere (to strike), especially prior to a definitive diagnosis.

A stroke is caused by the interruption of the blood supply to the brain usually because a blood vessel bursts or is blocked by a clot. This cuts off the supply of O2 and nutrients, causing damage to the brain tissue.

the most common symptom of stroke is sudden weakness or numbness of the face, arm, leg, most often on one side of the body. Other symptoms include: confusion, difficulty in speaking or understanding speech; difficulty seeing with one or both eyes; difficulty walking, dizziness, loss of balance or coordination; severe headache with no known cause; fainting or unconscious.

Stroke is medical emergency and can cause permanent Stroke is medical emergency and can cause permanent neurological damage complications and death if not promptly diagnosed and neurological damage complications and death if not promptly diagnosed and treated. It is the third leading cause of death and the leading cause of adult treated. It is the third leading cause of death and the leading cause of adult disability in the United States and Europe. It is predicted that stroke will soon disability in the United States and Europe. It is predicted that stroke will soon become the leading cause of death worldwide. Risk factors for stroke become the leading cause of death worldwide. Risk factors for stroke include; advanced age, hypertension, TIA (transient ischemic attack), include; advanced age, hypertension, TIA (transient ischemic attack), diabetes, high cholesterol, cigarette smoking, atrial fibrillation, migraine with diabetes, high cholesterol, cigarette smoking, atrial fibrillation, migraine with aura, thrombophilia. Blood pressure is the most important modified risk aura, thrombophilia. Blood pressure is the most important modified risk factor of stroke.factor of stroke.

The traditional definition of stroke, devised by the World Health The traditional definition of stroke, devised by the World Health Organization in the 1970s, is a “neurological deficit of cerebrovascular Organization in the 1970s, is a “neurological deficit of cerebrovascular cause that persists beyond 24 hours or is interrupted by death within 24 cause that persists beyond 24 hours or is interrupted by death within 24 hours”. This definition was supposed to reflect the reversibility of tissue hours”. This definition was supposed to reflect the reversibility of tissue damage and was devised for the purpose, with the time frame of 24 hours damage and was devised for the purpose, with the time frame of 24 hours being chosen arbitrarily. It divide stroke from TIA, which is related syndrome being chosen arbitrarily. It divide stroke from TIA, which is related syndrome of stroke symptoms that resolve completelt with in 24 hours. With the of stroke symptoms that resolve completelt with in 24 hours. With the availability of treatments that when given early can reduce stroke severity, availability of treatments that when given early can reduce stroke severity, many now prefer alternative concepts many now prefer alternative concepts such as such as brain attackbrain attack and and acute acute ischemic cerebrovascular syndrome, ischemic cerebrovascular syndrome, that reflect the urgency of stroke that reflect the urgency of stroke symptoms and the need to act swiftly.symptoms and the need to act swiftly.

The effects of a stroke depend on which part of the brain is injured and The effects of a stroke depend on which part of the brain is injured and how severely it is affected. A very severe stroke can cause sudden death.how severely it is affected. A very severe stroke can cause sudden death.

CausesCausesA CVA may be caused by any of the following:A CVA may be caused by any of the following:

A piece of fatty plaque (debris) that is formed in a blood vessel breaks A piece of fatty plaque (debris) that is formed in a blood vessel breaks away and flows through the bloodstream going to the brain. The plaque away and flows through the bloodstream going to the brain. The plaque blocks an artery which causes as stroke. This is called blocks an artery which causes as stroke. This is called embolic stroke.embolic stroke.

A thrombus (blood clot) formed in an artery (blood vessel) and blocked A thrombus (blood clot) formed in an artery (blood vessel) and blocked blood flow the brain. This is called a blood flow the brain. This is called a thrombotic strokethrombotic stroke..

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

Blockage of certain small blood vessels inside the brain.Blockage of certain small blood vessels inside the brain.

The following factors may put you at a higher risk of having a CVA:The following factors may put you at a higher risk of having a CVA: Cigarette smoking, cocaine use, or drinking too much alcohol.Cigarette smoking, cocaine use, or drinking too much alcohol. Diabetes (high blood sugar)Diabetes (high blood sugar) You or a close family member has had a stroke.You or a close family member has had a stroke. Atherosclerosis (hardening of the arteries) or fatty cholesterol deposits on Atherosclerosis (hardening of the arteries) or fatty cholesterol deposits on

artery walls.artery walls. Heart disease, such as coronary artery disease.Heart disease, such as coronary artery disease. High blood cholesterol (fat) and high blood pressure.High blood cholesterol (fat) and high blood pressure.

Signs and SypmtomsSigns and SypmtomsStroke symptoms typically develop rapidly (seconds to Stroke symptoms typically develop rapidly (seconds to minutes). The symptoms of a stroke are related to the minutes). The symptoms of a stroke are related to the anatomical location of the damage; nature and severity anatomical location of the damage; nature and severity of the symptoms can therefore vary widely. Ischemic of the symptoms can therefore vary widely. Ischemic strokes usually only affect regional areas of the brain strokes usually only affect regional areas of the brain perfused by the blocked artery. Hemorrhagic strokes can perfused by the blocked artery. Hemorrhagic strokes can affect local areas, but often can also cause more global affect local areas, but often can also cause more global symptoms due to bleeding and increased intracranial symptoms due to bleeding and increased intracranial pressure. On the basis of the history and neurological pressure. On the basis of the history and neurological examination, as well as the presence of risk factors, a examination, as well as the presence of risk factors, a doctor can rapidly diagnose the doctor can rapidly diagnose the anatomicalanatomical nature of the nature of the stroke (i.e. which part of the brain is affected), even if the stroke (i.e. which part of the brain is affected), even if the exact cause is not yet known.exact cause is not yet known.

Pre-hospital care professionals in the United Kingdom will typically want to identify stroke risk very rapidly. If they suspect a stroke, they will typically use the Face Arm Speech Test (FAST) to assess likelihood:

Face - look to see if there is any drooping or loss of muscle tone on the face

Arm - ask the patient to close their eyes and hold both arms out straight for 30 seconds - in a patient with a stroke, you might see one arm tending to slowly move down

Speech - listen to see if you can hear any slurring of the speech not otherwise explained (e.g. alcohol) and see if they can answer simple questions (where are you?, what's your name?, what day of the week is it?)

If the area of the brain affected contains one of the three prominent Central nervous system pathways—the spinothalamic tract, corticospinal tract, and dorsal column (medial lemniscus), symptoms may include:•hemiplegia and muscle weakness of the face •numbness •reduction in sensory or vibratory sensation

In most cases, the symptoms affect only one side of the body (unilateral). The defect in the brain is usually on the opposite side of the body (depending on which part of the brain is affected). However, the presence of any one of these symptoms does not necessarily suggest a stroke, since these pathways also travel in the spinal cord and any lesion there can also produce these symptoms.

In addition to the above CNS pathways, the brainstem also consists of the 12 cranial nerves. A stroke affecting the brainstem therefore can produce symptoms relating to deficits in these cranial nerves:

•altered smell, taste, hearing, or vision (total or partial) •drooping of eyelid (ptosis) and weakness of ocular muscles •decreased reflexes: gag, swallow, pupil reactivity to light •decreased sensation and muscle weakness of the face balance problems and nystagmus •altered breathing and heart rate •weakness in sternocleidomastoid muscle with inability to turn head to one side •weakness in tongue (inability to protrude and/or move from side to side)

If the If the cerebral cortexcerebral cortex is involved, the CNS pathways can again be affected, but also can is involved, the CNS pathways can again be affected, but also can produce the following symptoms:produce the following symptoms:

aphasiaaphasia (inability to speak or understand language from involvement of (inability to speak or understand language from involvement of Broca'sBroca's or or Wernicke's areaWernicke's area) )

apraxiaapraxia (altered voluntary movements) (altered voluntary movements) visual fieldvisual field defect defect memory deficits (involvement of memory deficits (involvement of temporal lobetemporal lobe) ) hemineglecthemineglect (involvement of parietal lobe) (involvement of parietal lobe) disorganized thinking, confusion, hypersexual gestures (with involvement of frontal disorganized thinking, confusion, hypersexual gestures (with involvement of frontal

lobe) lobe) anosognosia (persistent denial of the existence of a, usually stroke-related, deficit) anosognosia (persistent denial of the existence of a, usually stroke-related, deficit) If the If the cerebellumcerebellum is involved, the patient may have the following: is involved, the patient may have the following: trouble walking trouble walking altered movement coordination altered movement coordination vertigo and or disequilibrium vertigo and or disequilibrium Loss of consciousness, headache, and vomiting usually occurs more often in Loss of consciousness, headache, and vomiting usually occurs more often in

hemorrhagic stroke than in thrombosis because of the increased intracranial pressure hemorrhagic stroke than in thrombosis because of the increased intracranial pressure from the leaking blood compressing on the brain.from the leaking blood compressing on the brain.

If symptoms are maximal at onset, the cause is more likely to be a subarachnoid If symptoms are maximal at onset, the cause is more likely to be a subarachnoid hemorrhage or an embolic stroke.hemorrhage or an embolic stroke.

How is it diagnosed? How is it diagnosed? If symptoms of a stroke occur, someone If symptoms of a stroke occur, someone

should call an ambulance or take you to an should call an ambulance or take you to an emergency room right away. emergency room right away.

Your health care provider will know from your Your health care provider will know from your symptoms and physical exam whether you are symptoms and physical exam whether you are having a stroke. having a stroke.

The following tests may be done: The following tests may be done: lab tests of your blood lab tests of your blood electrocardiogram (ECG) to see how well your electrocardiogram (ECG) to see how well your

heart is working heart is working x-ray of your chest x-ray of your chest brain scans (CT or MRI) to try to identify a stroke brain scans (CT or MRI) to try to identify a stroke

and determine whether it is from a clot or from and determine whether it is from a clot or from bleeding into the brain from a leaking artery bleeding into the brain from a leaking artery (hemorrhage). (hemorrhage).

TreatmentTreatmentTreatment of CVA depends upon the type of stroke:Treatment of CVA depends upon the type of stroke: Ischemic stroke: An ischemic stroke includes stokes caused by Ischemic stroke: An ischemic stroke includes stokes caused by

a blockage in a blood vessel.a blockage in a blood vessel.- Anticoagulant medicine: treatment for an ischemic - Anticoagulant medicine: treatment for an ischemic

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

- Antiplatelet aggregating medicine: these medicines - Antiplatelet aggregating medicine: these medicines interact with platelets to prevent blood clots from forming. interact with platelets to prevent blood clots from forming. Platelets are type of blood cell that joins to form clots.Platelets are type of blood cell that joins to form clots.

- Thrombolytic medicine: this medicine group is used in - Thrombolytic medicine: this medicine group is used in a stroke caused by a clot ion a blood vessel. Thrombolytics a stroke caused by a clot ion a blood vessel. Thrombolytics break apart clot and restore blood flow.break apart clot and restore blood flow.

Hemorrhagic (bleed) stroke: this type of stroke may require Hemorrhagic (bleed) stroke: this type of stroke may require surgery.surgery.

Immediate treatmentImmediate treatment

In hospital, brain scans are needed to find out what In hospital, brain scans are needed to find out what type of stroke you've had. type of stroke you've had. If a blood clot is the cause, 'clot busting' medication may If a blood clot is the cause, 'clot busting' medication may

be used to dissolve the clot, but this must be given within be used to dissolve the clot, but this must be given within three hours of the stroke. Anti-clotting medication such as three hours of the stroke. Anti-clotting medication such as aspirin may also be given to stop the stroke from getting aspirin may also be given to stop the stroke from getting worse. worse.

Anti-clotting medication is not given in strokes caused by Anti-clotting medication is not given in strokes caused by haemorrhaging because it will make the bleeding worse.haemorrhaging because it will make the bleeding worse.

Other treatment includes:Other treatment includes: tests on key functions like swallowing and movementtests on key functions like swallowing and movement checks on oxygen, glucose and blood pressure levels.checks on oxygen, glucose and blood pressure levels.

If swallowing is affected, you may be fed by a tube or If swallowing is affected, you may be fed by a tube or given fluids into a vein (intravenously) to avoid food given fluids into a vein (intravenously) to avoid food going into the lungs.going into the lungs.

After a stroke

In the first few days after a stroke, treatment concentrates on making sure you are well hydrated and nourished.

The next phase of treatment is recovery through rehabilitation. This involves a team of health professionals including physiotherapists, speech therapists, occupational therapists, nurses and doctors.

If a stroke is caused by a blood clot, then taking a low-dose aspirin (eg Nu-seals 75mg) once a day may help make the blood less sticky and less likely to cause clots.

PreventionPrevention Take your high blood pressure medicine regularly.Take your high blood pressure medicine regularly. Don not smoke or drink too much alcohol. Alcohol is found in beer, Don not smoke or drink too much alcohol. Alcohol is found in beer,

wine, liquor, like vodka or whiskey, and other adult drinks. Different wine, liquor, like vodka or whiskey, and other adult drinks. Different people have different ideas about what too much means. It is important people have different ideas about what too much means. It is important as how much you drink.as how much you drink.

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

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

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

If necessary, a physician may also order medication to lower blood If necessary, a physician may also order medication to lower blood pressure. These medications include the following categories of drugs:pressure. These medications include the following categories of drugs:

Beta blockers are used to reduce the force and speed of the heart-beat. Beta blockers are used to reduce the force and speed of the heart-beat. Vasodilators are used to dilate the blood vessels. Vasodilators are used to dilate the blood vessels. Diuretics reduce the total volume of circulating blood and thus the Diuretics reduce the total volume of circulating blood and thus the

heart's work by removing fluid from the body. heart's work by removing fluid from the body. Lipid-lowering drugs increase the loss of cholesterol from the body or Lipid-lowering drugs increase the loss of cholesterol from the body or

prevent the conversion of fatty acids to cholesterol. This lowers fat prevent the conversion of fatty acids to cholesterol. This lowers fat levels in the bloodstream. levels in the bloodstream.

PrognosisPrognosisThe National Institute of Neurological Disorders and The National Institute of Neurological Disorders and

Stroke reports that 25% of people who suffer a stroke recover Stroke reports that 25% of people who suffer a stroke recover completely, while 20% die within three months after the stroke. completely, while 20% die within three months after the stroke. Stroke is fatal for nearly twice as many people of African-Stroke is fatal for nearly twice as many people of African-American heritage as it is for European-Americans. Of the American heritage as it is for European-Americans. Of the remaining 55% of people who have strokes, 5% will require remaining 55% of people who have strokes, 5% will require long-term (nursing home) care. For the rest, rehabilitative and long-term (nursing home) care. For the rest, rehabilitative and restorative services will be necessary in order for them to restorative services will be necessary in order for them to regain as much of their former capabilities as possible.regain as much of their former capabilities as possible.

Disability affects 75% of stroke survivors enough to Disability affects 75% of stroke survivors enough to decrease their employability. Stroke can affect patients decrease their employability. Stroke can affect patients physically, mentally, emotionally, or a combination of the three. physically, mentally, emotionally, or a combination of the three. The results of stroke vary widely depending on size and The results of stroke vary widely depending on size and location of the lesion. Dysfunctions correspond to areas in the location of the lesion. Dysfunctions correspond to areas in the brain that have been damaged.brain that have been damaged.

NURSING HEALTH HISTORY

Biographic Data:Name of Patient: Mr. V.E.Address: Canlanipa Housing, Surigao CityAge: 46 years oldSex: MaleCivil Status: Married Date of Birth: November 21, 1962Religion: Roman CatholicHighest Educational Attainment: College Graduate Degree: Bachelor of Science in Civil EngineeringOccupation: Government Employee

Health care financing and usual source of medical care: Phil HealthSource and reliability of data gathered: Primary source (patient’s wife) and secondary sources (chart and the SOs)

Admission Data:

Hospital: Surigao Medical CenterCase No.: 39558Room: PR - 25Date Admitted: August 11, 2009Time Admitted: 7:45 pmArrived via: per stretcherAdmitting vital signs:

T- 36.8°CRR- 22 cpmPR- 92 bpmBP- 160/100 mmHg

Weight:Height: 5’10Admitting Physician: Dr. Gilberto A. BarcenasAttending Physician: Dr. Roy N. YcongChief Complaint:Left side weakness and semi-unconscious and

slurred speech.Impression: CVA Thrombosis seconday to HypertensionFinal Diagnosis: Cerebrovascular Accident – thrombosis with Right

Paralysis; HPN

HISTORY OF PRESENT ILLNESSA 46 year-old patient was admitted in Surigao Medial Center

last August 11, 2009 at exactly 7:45 pm because of left side weakness and semiconscious with slurred speech. As day before hospitalization, he attended a wedding of his brother. According to the SO, the patient had eaten too much fatty foods such as homba, lechon, etc. and got drunk. The next day, he woke up early in the morning and prepared insisted to go to wok. While doiung his duty in office he got collapsed. This prompted his co-officemate to seek medical attention at SMC. Upon admission his BP was high (160/100mmHg), hemiparesis and hemiplegia were noted on the left side of the body. The patient was semiconscious and he had difficulty in speaking and responding to verbal commands.

It was his 1sy time to be diagnosed with CVA. Furthermore, patient is taking Captopril 75 mg 1 tab daily, an anti-hypertensive drug as his maintenance for his hypertension.

PAST HEALTH HISTORYPAST HEALTH HISTORY

Childhood IllnessChildhood IllnessAccording to the informant, the patient experienced sore eyes According to the informant, the patient experienced sore eyes when she was 9 yrs. old and mumps when she was 13 yrs. old. The when she was 9 yrs. old and mumps when she was 13 yrs. old. The patient did not complete his immunization, only hepatitis B patient did not complete his immunization, only hepatitis B vaccine.vaccine.

History of Hospitalization History of Hospitalization Patient doesn’t have any history of hospitalization. Patient doesn’t have any history of hospitalization. Although, sometimes he seeks for a medical check-upAlthough, sometimes he seeks for a medical check-up

Family Health HistoryFamily Health History

The patient has 5 siblings with 3 girls and 2 boys in the The patient has 5 siblings with 3 girls and 2 boys in the family. He is the fourth from the eldest child. He is family. He is the fourth from the eldest child. He is married and blessed with one child. Both of his parents married and blessed with one child. Both of his parents had a history of hypertension and died because of had a history of hypertension and died because of Stroke. His 52 years old sibling had Diabetes Mellitus. Stroke. His 52 years old sibling had Diabetes Mellitus. The usual sickness the patient’s families often The usual sickness the patient’s families often encountered are the common colds, fever, cough and encountered are the common colds, fever, cough and headache.headache.

Personal Health HistoryPersonal Health History

LIFESTYLELIFESTYLEThe patient was indulged in drinking alcohol if there are occasions with The patient was indulged in drinking alcohol if there are occasions with San Miguel Beer about a minimum of 1 liter or sometimes 1 case of San Miguel Beer about a minimum of 1 liter or sometimes 1 case of beer with his colleges and during high school days.And an active beer with his colleges and during high school days.And an active smoker as his past time in which he can consume 3 packs of cigarette smoker as his past time in which he can consume 3 packs of cigarette per day as stated by the SO. He is a person who loves to stay and have per day as stated by the SO. He is a person who loves to stay and have fun together with his friends and co-officemate. fun together with his friends and co-officemate.

SLEEP AND REST PATTERNSSLEEP AND REST PATTERNSBefore hospitalization, patient usually sleeps at 9 pm and wakes up at Before hospitalization, patient usually sleeps at 9 pm and wakes up at around 5 am; usually 8 hours of sleep . But during his hospitalization, around 5 am; usually 8 hours of sleep . But during his hospitalization, his sleeping pattern was in interrupted due to his condition. He had his sleeping pattern was in interrupted due to his condition. He had irregular sleep and wake up pattern as stated by the SO.irregular sleep and wake up pattern as stated by the SO.

ELIMINATION PATTERNELIMINATION PATTERNThe patient defecated twice a day and urinated 4-6 times a day and he The patient defecated twice a day and urinated 4-6 times a day and he don’t have any difficulties in urination and defecation before his don’t have any difficulties in urination and defecation before his hospitalization. But during our assessment in the hospital, he never hospitalization. But during our assessment in the hospital, he never defecated during day and with a dwelling Folley bag catheter.defecated during day and with a dwelling Folley bag catheter.

ACTIVITIES OF DAILY LIVINGACTIVITIES OF DAILY LIVINGBefore hospitalization, our patient takes a bath every day; go Before hospitalization, our patient takes a bath every day; go

on duty in a government office every weekday as claimed by the SO. on duty in a government office every weekday as claimed by the SO. Oftentimes, he makes use of his vacant time hanging out with his Oftentimes, he makes use of his vacant time hanging out with his family and sometimes goes on gimmick with his friends. family and sometimes goes on gimmick with his friends.

RECREATION AND HOBBIESRECREATION AND HOBBIESAs claimed, he loves to play with his 1 child and listen to radio. As claimed, he loves to play with his 1 child and listen to radio.

He also goes to church every Sunday to attend the mass as stated. He also goes to church every Sunday to attend the mass as stated. Oftentimes, he strolls on a Sunday night riding his motorcycle.Oftentimes, he strolls on a Sunday night riding his motorcycle.

Social DataSocial DataOur patient is a college graduate of Bachelor of Science in Civil Our patient is a college graduate of Bachelor of Science in Civil Engineering as stated by the SO. Patient’s support systems are her Engineering as stated by the SO. Patient’s support systems are her family and friends. Currently he is a government employee, according family and friends. Currently he is a government employee, according to his wife; he is so devoted on his work. Patient doesn’t have to his wife; he is so devoted on his work. Patient doesn’t have experience any history of accidents on the job.experience any history of accidents on the job.

Environmental DataEnvironmental DataThe patient’s house is situated near the basketball court in Canlanipa The patient’s house is situated near the basketball court in Canlanipa Housing wherein the houses are closed to each other. Their house is Housing wherein the houses are closed to each other. Their house is made up of cemented materials and they live in a peaceful, clean and made up of cemented materials and they live in a peaceful, clean and green environment as described by the SO. green environment as described by the SO.

Psychologic DataPsychologic DataBefore hospitalization, the patient was an energetic and Before hospitalization, the patient was an energetic and fun to be with husband as stated by his wife. There are fun to be with husband as stated by his wife. There are times that the patient felt upset if something will happen times that the patient felt upset if something will happen to his family.to his family.

Patterns of Health CarePatterns of Health CareThe patient did not consult any annual check-ups nor The patient did not consult any annual check-ups nor visited even a dentist. The patient and his family used visited even a dentist. The patient and his family used herbal plants as alternative medicine such as “carabo” herbal plants as alternative medicine such as “carabo” for cough and “helbas” for abdominal pain as verbalized for cough and “helbas” for abdominal pain as verbalized by the SO. by the SO.

Nutritional PatternNutritional PatternBefore hospitalization, patient’s typical on a normal day Before hospitalization, patient’s typical on a normal day was consists of meat, fish and vegetables. Aside from was consists of meat, fish and vegetables. Aside from that, he ate snack 3 times a day. Patient’s don’t have any that, he ate snack 3 times a day. Patient’s don’t have any food allergies, as claimed by the SO. food allergies, as claimed by the SO.

PHYSICAL ASSESSMENT

General Survey Patient lies on bed conscious, weak, with a signs of

cardiac or respiratory distress. He appears weak, restless, agitated and irritable. Patient is afebrile and has an IVF of PNSS infusing well at the right metacarpal vein at the level 620 cc with a drop rate of 20 gtts/min. Patient has an O2 inhalation at 3L/min via nasal .

 Vital Signs:

Date of Assessment: August 12, 2009T- 36.3 oC RR- 26 cpm PR- 96 bpm BP- 160/100 mmHg

 

INTEGUMENTARY: Skin

Patient has brown complexion and uniform in color Negative in pigmentation Warm, smooth and moist skin upon palpation Good skin turgor noted No tenderness upon palpation both in right and left part of the body No edema noted upon inspection. Perspiration noted

Hair Hair is evenly distributed on the scalp upon inspection. Thick and black hair with a few streaks of graying hair upon inspection

but not that prominent yet Uncombed hair noted upon inspection With no infestation of dandruffs or flaking upon inspection. Variable amount of body hair with beard noted upon inspection 

NailsNails Convex curvature of nail in shape and dirty upon inspection.Convex curvature of nail in shape and dirty upon inspection. Slightly rough in texture upon palpation.Slightly rough in texture upon palpation. Intact epidermis surrounding the fingernails and toe nails upon inspection. Intact epidermis surrounding the fingernails and toe nails upon inspection. Capillary refill test of less than 3 seconds unaffected side and more than 3 seconds Capillary refill test of less than 3 seconds unaffected side and more than 3 seconds

at affected side and more than 3 seconds on toes.at affected side and more than 3 seconds on toes.    HEENT: HEENT:

Skull and FaceSkull and Face

Rounded and normocephalic skull contour and no scars upon inspection.Rounded and normocephalic skull contour and no scars upon inspection. Smooth, uniform consistency of the skull upon palpation.Smooth, uniform consistency of the skull upon palpation. Absence of nodules or masses upon palpation.Absence of nodules or masses upon palpation. Right Flaccidity faced noteRight Flaccidity faced note

Eyes and VisionEyes and Vision Thick eyebrows and lashes are noted upon inspectionThick eyebrows and lashes are noted upon inspection No abnormal discharges of the eyes upon inspection. No abnormal discharges of the eyes upon inspection. Lids close symmetrically upon inspection.Lids close symmetrically upon inspection. Sclera appears white upon inspection.Sclera appears white upon inspection. No edema or tenderness noted over periorbital area upon inspection and palpation.No edema or tenderness noted over periorbital area upon inspection and palpation. Pupils are black and equal in size upon inspection (5 mm)Pupils are black and equal in size upon inspection (5 mm) Blurred vision, cant read with ( RANGED)Blurred vision, cant read with ( RANGED) 8 involuntary blink reflexes noted in 1 minute. 8 involuntary blink reflexes noted in 1 minute. Drowsy eyes notedDrowsy eyes noted

Ears and HearingEars and Hearing

Symmetric ear position that lines with outer canthus of the eye upon Symmetric ear position that lines with outer canthus of the eye upon inspection.inspection.

Auricles are mobile, firm, and not tender upon palpation.Auricles are mobile, firm, and not tender upon palpation. Pinna recoils after it is folded. Pinna recoils after it is folded. No abnormal discharges noted No abnormal discharges noted Auricles are of the same color with the facial skin upon inspection.Auricles are of the same color with the facial skin upon inspection. Difficulty in hearing on the left earDifficulty in hearing on the left ear

   Nose and SinusesNose and Sinuses

Nose is symmetrical and straight upon inspection.Nose is symmetrical and straight upon inspection. No discharges or flaring noted upon inspection.No discharges or flaring noted upon inspection. External nose has same color as facial skinExternal nose has same color as facial skin Right mole noted on the upper part of the noseRight mole noted on the upper part of the nose Nasal septum is intact and in midline upon inspection.Nasal septum is intact and in midline upon inspection. No tenderness and lesions on both nose and sinuses noted upon No tenderness and lesions on both nose and sinuses noted upon

palpation.palpation. NGT attachedNGT attached Oxygen attached (3L/min)Oxygen attached (3L/min)

Oropharynx (mouth and throat)Oropharynx (mouth and throat) Lips has symmetric contour; uniform and brownish in color, soft Lips has symmetric contour; uniform and brownish in color, soft

and slightly dry upon inspection and palpation.and slightly dry upon inspection and palpation. Has ability to purse lips upon inspection.Has ability to purse lips upon inspection. Slightly dark gums and plaque noted on the enamel upon Slightly dark gums and plaque noted on the enamel upon

inspection.inspection. No presence of dentures upon inspection.No presence of dentures upon inspection. Able to move tongue and positioned centrally upon inspection.Able to move tongue and positioned centrally upon inspection. Lacking 2 lower molars upon inspectionLacking 2 lower molars upon inspection Halitosis notedHalitosis noted With NGT attachedWith NGT attached Negative gag and swallowing reflexes notedNegative gag and swallowing reflexes noted

Neck Neck Neck muscles are equal in size upon inspection.Neck muscles are equal in size upon inspection. With head centered upon inspection.With head centered upon inspection. Slightly enlarged neck noted upon inspectionSlightly enlarged neck noted upon inspection Can hyperextend and flex neck but in a slower pace upon Can hyperextend and flex neck but in a slower pace upon

inspection.inspection. Coordinated smooth movements of the head upon inspection.Coordinated smooth movements of the head upon inspection. Thyroid gland is not visible upon inspection.Thyroid gland is not visible upon inspection. Lymph nodes are not evident/palpable upon palpation.Lymph nodes are not evident/palpable upon palpation. No jugular vein distention was noted upon inspection.No jugular vein distention was noted upon inspection.

THORAX AND LUNGSTHORAX AND LUNGS Chest is symmetrical upon inspection.Chest is symmetrical upon inspection. Skin is intact and uniform in color both anterior and posterior upon inspection and Skin is intact and uniform in color both anterior and posterior upon inspection and

palpation.palpation. Chest wall intact and no tenderness noted upon palpationChest wall intact and no tenderness noted upon palpation Antero-posterior diameter is 2:1Antero-posterior diameter is 2:1 Respiratory rate 26 cpm Respiratory rate 26 cpm O2 inhalation attach and no respiratory distress notedO2 inhalation attach and no respiratory distress noted Spinal column is vertically aligned and intact with no tenderness or masses noted Spinal column is vertically aligned and intact with no tenderness or masses noted

upon palpation.upon palpation.

CARDIOVASCULAR SYSTEM and PERIPHERAL VASCULAR SYSTEMCARDIOVASCULAR SYSTEM and PERIPHERAL VASCULAR SYSTEM. .

No abdominal aortic pulsations upon auscultation.No abdominal aortic pulsations upon auscultation. Pulse rate of 96 bpmPulse rate of 96 bpm Blood pressure of 160/100 mmHg Blood pressure of 160/100 mmHg Positive tactile fremitus upon palpationPositive tactile fremitus upon palpation Capillary refill test of less than 3 seconds unaffected side and more than 3 Capillary refill test of less than 3 seconds unaffected side and more than 3

seconds at affected side and more than 3 seconds on toes.seconds at affected side and more than 3 seconds on toes. Apical pulse palpable and no edema notedApical pulse palpable and no edema noted

  BREAST AND AXILLAEBREAST AND AXILLAE No masses, nodules, or tenderness noted upon palpation.No masses, nodules, or tenderness noted upon palpation. Same color as the skin of abdomen/back upon inspection.Same color as the skin of abdomen/back upon inspection. No discharges in the nipple noted upon inspection.No discharges in the nipple noted upon inspection.

ABDOMENABDOMEN

Small brown pigments on the abdominal skin noted upon inspection.Small brown pigments on the abdominal skin noted upon inspection. Uniform in color upon inspection.Uniform in color upon inspection. No evidence of enlargement of liver or spleen upon inspection and palpation.No evidence of enlargement of liver or spleen upon inspection and palpation. Symmetric abdominal contour upon inspection.Symmetric abdominal contour upon inspection. No rebound tenderness felt upon palpation No rebound tenderness felt upon palpation

MUSCULOSKELETAL SYSTEMMUSCULOSKELETAL SYSTEM

Pulse is palpable on distal part of the extremities when palpatedPulse is palpable on distal part of the extremities when palpated Slow coordinated movements notedSlow coordinated movements noted Muscle strength is 4/5Muscle strength is 4/5 Paresthesia and paresis noted in the left side of the bodyParesthesia and paresis noted in the left side of the body No edema noted upon inspection. No edema noted upon inspection. Easy fatigability noted  Easy fatigability noted  Patient unable to do ADL’sPatient unable to do ADL’s

MENTAL STATUS MENTAL STATUS

    Language Language During the first day of assessment the patient has difficulty in speaking During the first day of assessment the patient has difficulty in speaking

as evidenced by slurred speech but able to comprehend spoken words. as evidenced by slurred speech but able to comprehend spoken words.

Orientation Orientation Patient is not oriented to time but he knows who’s his talking to and Patient is not oriented to time but he knows who’s his talking to and

where he was. He wasn’t able to explain that the reason for seeking where he was. He wasn’t able to explain that the reason for seeking healthcare service, but identify present location, recognize persons in healthcare service, but identify present location, recognize persons in his room and but not specifically in date and time upon assessment.his room and but not specifically in date and time upon assessment.

Memory Memory He was able to recognize the people who surround him. As to long term He was able to recognize the people who surround him. As to long term

events, he was able to recall where he grew up by asking some question events, he was able to recall where he grew up by asking some question and he nags his head if correct.and he nags his head if correct.

Glasgow Coma ScaleGlasgow Coma Scale● ● Eye Opening- to voice on request = 2Eye Opening- to voice on request = 2● ● Motor Response- to verbal command = 3Motor Response- to verbal command = 3● ● Verbal Response- oriented, converses = 3Verbal Response- oriented, converses = 3

Score: 8/15 – slightly comaScore: 8/15 – slightly coma   

REVIEW OF SYSTEMS (ROS)REVIEW OF SYSTEMS (ROS)Date of assessment: August 14, 2009Date of assessment: August 14, 2009General Data:General Data:

Patient lies on bed conscious, coherent, and responsive with signs Patient lies on bed conscious, coherent, and responsive with signs of cardiac or respiratory distress. He appears weak, restless, agitated and of cardiac or respiratory distress. He appears weak, restless, agitated and irritable. Patient is afebrile and has an IVF, of PNSS infusing well at the right irritable. Patient is afebrile and has an IVF, of PNSS infusing well at the right metacarpal vein at the level 620 cc running with a drop rate of 20. Patient metacarpal vein at the level 620 cc running with a drop rate of 20. Patient has an O2 inhalation via nasal cannula at 3 L/minhas an O2 inhalation via nasal cannula at 3 L/min

Integumentary System:Integumentary System: As what the so verbalized, the patient had no history of skin As what the so verbalized, the patient had no history of skin

itchiness, and no pigmented spots on the upper and lower extremities. He itchiness, and no pigmented spots on the upper and lower extremities. He has a warm, moist skin and oftentimes experience sweating. No hair dyes, has a warm, moist skin and oftentimes experience sweating. No hair dyes, curling/ straightening preparations were used. curling/ straightening preparations were used.

Head, Eyes, Ears, Nose, Throat (HEENT):Head, Eyes, Ears, Nose, Throat (HEENT): Patient has no history of head trauma. Patient uses eyeglasses Patient has no history of head trauma. Patient uses eyeglasses

because he is unable to read small written words or phrases. Patient also because he is unable to read small written words or phrases. Patient also claimed that at times he experienced headache, dizziness and light claimed that at times he experienced headache, dizziness and light headedness which are usually aggravated by heavy work. Patient has no headedness which are usually aggravated by heavy work. Patient has no history of ear infection.history of ear infection.

Neck: Neck:    Patient said that when he works too much he sometimes experienced neck Patient said that when he works too much he sometimes experienced neck

and back pain and were relieved through using “and back pain and were relieved through using “SalonpasSalonpas” and “” and “hilothilot” or massage. ” or massage.

Breast and Axillae: Breast and Axillae: Patient did not experience any pain on his breast area. Patient did not experience any pain on his breast area.

Thorax and Lungs: Thorax and Lungs: Patient verbalized that he did not have any major lung diseases experienced, Patient verbalized that he did not have any major lung diseases experienced,

like lung cancer and PTB. like lung cancer and PTB.

Cardiovascular System: Cardiovascular System: He said his usual BP is 160/100 mmHg and experiences palpitations. Patient He said his usual BP is 160/100 mmHg and experiences palpitations. Patient

stated that he experienced numbness, tingling sensation and observed poor wound stated that he experienced numbness, tingling sensation and observed poor wound healing. He also stated that he experienced fatigue every time he is over worked or healing. He also stated that he experienced fatigue every time he is over worked or under some emotional stress. He is a smoker and drinks alcoholic beverages. However under some emotional stress. He is a smoker and drinks alcoholic beverages. However he still drinks alcohol occasionally when he finds it difficult to decline when his friends he still drinks alcohol occasionally when he finds it difficult to decline when his friends cajole him whenever they get together but he insisted that on moderation only.cajole him whenever they get together but he insisted that on moderation only.

Gastrointestinal System: Gastrointestinal System: Patient claimed that there were few times when he finds it difficult to manage Patient claimed that there were few times when he finds it difficult to manage

his food intake especially when he was still working. Lately, he observed an increase his food intake especially when he was still working. Lately, he observed an increase appetite but tries so hard to curtail it for fear of Hypertension complications and it appetite but tries so hard to curtail it for fear of Hypertension complications and it resulted in increase weight and increase blood pressure. He has no known allergies in resulted in increase weight and increase blood pressure. He has no known allergies in terms of foods. He sometimes experienced incidence of diarrhea. His usual bowel habit terms of foods. He sometimes experienced incidence of diarrhea. His usual bowel habit is every day usually in the morning.  is every day usually in the morning. 

Musculoskeletal System: Musculoskeletal System: Patient claimed that he experienced neck and back pain when Patient claimed that he experienced neck and back pain when

his at work especially when having an over time. It was relieved through his at work especially when having an over time. It was relieved through relaxation techniques like taking sleep, sitting on a chair while watching relaxation techniques like taking sleep, sitting on a chair while watching television and frequents breaks while working. television and frequents breaks while working.

Urinary System:Urinary System:Patient claimed that he has no major complication in his kidney.Patient claimed that he has no major complication in his kidney.

    Hematologic: Hematologic:

Patient had no history of anemia, easy bruising and bleeding.  Patient had no history of anemia, easy bruising and bleeding.  

Neurologic System: Neurologic System: Patient said that he often have mood swings that sometimes Patient said that he often have mood swings that sometimes

lead to an argument with his wife over minute details which irate him. lead to an argument with his wife over minute details which irate him. He felt depressed when he was admitted. He felt nervous and tense for He felt depressed when he was admitted. He felt nervous and tense for his recent condition since he had relatives who died from stroke. He is his recent condition since he had relatives who died from stroke. He is anxious about his condition and its effects to his wife and children. This anxious about his condition and its effects to his wife and children. This is because he knows that stroke is an illness that requires a long time is because he knows that stroke is an illness that requires a long time to recuperate. He also feels guilt for maybe his condition now is a to recuperate. He also feels guilt for maybe his condition now is a repercussion of his behavior a few years ago. repercussion of his behavior a few years ago.

Phenytoin (Dilantin)

Classification: Anticonvulsants

Dosage: 100 mg 1 cap BID

Mechanism of Action: May stabilized neuronal membranes and limit seizure activity either

by increasing efflux or decreasing influx of Sodium oins across cell membranes in the motor cortex during generation of nerve impulses.

Indications:To control tonic – clonic and complex partial seizures.To prevent and treat seizures occurring during neurosurgery

Contraindication:Contraindicated in patients hypersensitive to hydantoin and in those with sinus bradycardia, SA, block, or Adams-strokes syndrome.Elderly patients tend to metabolize drug slowly and may need reduced dosage.

Adverse Effect:CNS: ataxia, decreased coordination, mental confusion, slurred speech,

dizziness and headache.CV: periarteritis nodosaEENT: diplopia, nystagmus, blurred visionGI: gingival hyperplasia, nausea, vomiting, constipatioHEMATOLOGIC: agranulocytosis, leucopenia, pancytopenia,

thrombocytopeniaHEPATIC: toxic hepatitisMETABOLIC: hyperglycemiaMUSCULOSKELETAL: osteomalaciaSKIN: Stevens-johnson syndrome, toxic epidermal necrolysis

Nursing consideration:• Don’t give IM unless dosage adjustments are made; drug may

precipitate at injection site.• Divided doses given with or after meals may decrease adverse GI

reaction.• Don’t stop drug suddenly because this may be worsen seizures.• Allow at least 7 to 10 days to elapse between dosage changes.• Mononucleosis may decrease level. Watch for increase seizures.

Tramadol (Milador)

Classification: Opioid Analgesic

Dosage: 1 cap TID / NGT

Mechanism of action:Unknown. A centrally acting synthetic analgesic compound

no chemically to opioids. Thought to bind to opioid receptors and inhibit reuptake to norepinephrine and serotonin.

Indication:Moderate to moderately severe pain.

Contraindications: Contraindicated in patients hypersensitivity to drugUse cautiously in patients with hepatic or renal disease, or history of drug or alcohol abuse.Patient with history of anaphylactic reaction to codeine and other opioids may be at increased risk.

Adverse effect:CNS: dizziness, headache, somnolence, vertigo, seizure, anxiety, astheniaCV: vasodilationEENT: visual disturbanceGI: constipation, nausea and vomiting, abdominal pain, anorexia,

diarrheaGU: menopausal symptoms, proteinuria, urinary frequencySKIN: diaphoresis, pruritus

Nursing Consideration:•Reassess patient’s level of pain at least 30 minutes after administration.•Monitor CV and respiratory status•Monitor bladder and bowel function•For better analgesic effect, give drug before onset of intense pain.•Monitor patient at risk of seizure.

Mannitol (Osmitrol)

Classification: Osmotic Diuretic

Dosage: 2 % 100 cc IV bolus q 120 starting in AM

Mechanism of action:Increases osmotic pressure of glomerular filtrate, inhibiting

tubular reabsorption of water and electrolytes; drug elevates plasma osmolality, increasing water flow into rxtracellular fluid.

Indication:test dose for maked oliguria or suspected inadequate renal function.OliguriaTo prevent oliguria or acute renal failure.To reduce intraocular or intracranial pressureDiureses in drug intoxication

Contraindication:Contraindicated in patients hypersensitive to drug.Contraindicated to patient with anuria;severe pulmonary congestion; frank pulmonary edema

Adverse reaction:CNS: dizziness, headache, fatigue, vertigo,

paresthesiaCV: orthostatic hypotension, palpitations, vasculitisGI: pancreatitis,anorexia, vomiting, nauseaGU: nocturia, polyuria, impotenceHEMATOLOGIC: aplastic anemia, leucopeniaHEPATIC: jaundice, hepatitisMUSKULOSKELETAL: muscle crampsSKIN: pruritus, rash, urticaria, dermatitis

Nursing consideration:•To prevent nocturia, give drug in the morning.•Monitor fluid intake and output, weight, blood pressure, and electrolyte levels.•Monitor glucose level, especially in diabetic patient.•Monitor blood pressure.

Piracetam (Nootropil)

Classification: Neurovascular enhancer Dosage: 1.2 gm IVTT

Mechanism of action:CNS stimulants, neuroleptics, thyroid hormones

Indication:Disturbances in cerebral activity due to advanced age, mental fatigue, lack of concentration, impaired memory, depressive states, emotional lability.

Contraindication:Contraindicated to patient with hypersensitivity to drug, to pregnant and lactated mother.

Adverse effect:Sexual stimulation, increased motor activity, troubled speech,

aggreesively, somnolence, increase in weight, depressive states.

PREVACID

Classification:Anti ulcer

Dosage: FGT 30 mg 1 cap once a day

Mechanism of action:Inhibits activity of proton pump and binds to hydrogen-

potassium adenosine triphosphate located at secretory surface of the gastric parietal cells to block secection of gastric acid.

Indication:Short term treatment of active duodenal ulcer.

Contraindication:Contraindicated to patients hypersensitive to drug.

Adverse effect:GI: abdominal pain, diarrhea, nausea

Nursing consideration:1. Patients with severe liver disease may need dosage adjustment, but don’t adjust the dosage for elderly patients or those with renal insufficiency.2. The contents of capsule can be mixed 40 ml of apple juice in a syringe and given within 3-5 minutes via a nasogastric tube. Flush with additional apple juice to give entire dose and maintain patency of the tube. 3. To give ODT’s through an NG tube 8 French or larger, dissolve a 15 mg tablet in 4 ml water or a 30 mg tablet in 10 ml water and give within 15 minutes. Refill the syringe with about 5 ml of water, shake gently and give any remaining contents. 4. Its unknown if drug appears in breast milk. Breast feeding women should either stop breast-feeding or stop drug.

Metronidazole (Zolmid)

Classification: Antiprotozoal,Antibacterial

Dosage: 500 mg IV infusion q 8 hours

Mechanism of action:Direct-acting trichomonacide and amebicide that works inside and

outside the intestines.

Indication:1. Amebic liver abcess.2. Bacterial infections caused by anaerobic microorganisms. 3. Intestinal amebiasis.

Contraindication:1. Contraindicated to patients hypersensitive to drug or to other nitroimidazole derivatives and in women in first trimester pregnancy. 2. Alert: If drug must be given to a pregnant women for trichomoniasis use the 7-day regimen not the 2 gm single dose regimen. The 2 g regimen produces a high level that’s more likely to reach fetal circulation. 3. use cautiously in patients with history of blood dyscrasias, CNS disorder or retinal or visual field changes.

Adverse effect:CNS: headache, seizures, fever, vertigoCV: flattened T wave, edema, flushing, thrombophlebitisEENT: rhinitis, sinusitis, pharyngitis GI: nausea, abdominal cramping or pain GU: vaginitis, duodenal ulcer, polyurea, dysuria RESPIRATORY: upper respiratory tract infection. Nursing consideration:1. Monitor liver function test results carefully in elderly patients.2. Give oral forms with meals.3. Observe patients for edema, especially if he’s receiving corticosteroids, Flagyl RTU may cause sodium retention.4. Record number and character of stools when drug is used to treat amebiasis.

CITICOLINE (Zynapse)Classification:

Dose order/frequency/route:500 mg IVTT q 6O

Mechanism of action:It activates the bio-synthesis of structural phospholipids in the

neuronal membrane, increases cerebral metabolism and increases the level of various neurotransmitters, including acetylcholine and dopamine. Citicoline has shown nueroprotective effects in situation of hypoxia and ischemia, as well as improved learning and memory performance in animal models of the brain aging. Furthermore, it has been demonstrated that citicoline restores the activation of phospholipase A2 and accelerates the reabsorption of cerebral edema in various experimental models.Indications:

Cerebrovascular diseases; head trauma of varying severity; cognitive disorders of various etiology.Contraindications:

Patients with hypertonia of the parasympathetic.Adverse Reactions:

May exert a stimulating action of the parasympathetic, as well as a fleeting and discrete hypotensor effect.

PLETAALDose ordered/ frequency/route:

50mg 1 tab p.o. ODClassification:

Anti-coagulant/anti-plateletsMechanism of Action:

Therapeutic agent’s can’t cure convulsions disorder but do control seizures without impairing the normal function of the CNS. This is often accomplished by selective depression of hyperactive areas of the brain responsible for the convulsants.Indication;

Pain and cold sensation in chronic arterial occlusionContraindication:

Contraindicated in patient with hypersensitivity to drug. Adverse Effect:

CNS: headache, seizures, comaEENT: decreased intraocular pressureGI: nausea and vomiting, diarrhea, anorexia, candidiasisGU: protienuria, nephrotoxicity

Nursing Considerations:○ check for medical history for hypersensitivity to anti-convulsant

drugs○ don’t discontinue abruptly unless provider approved○ be prepared in case of acute oral toxicity

Atorvastatin Calcium (Lipitor)

Classification: HMG-CoA reductase inhibitor

Dosage Order: 10 mg 7 tab P.C. supper

Mechanism of Action:Inihibits HMG-CoA reductase, an early step in cholesterol biosynthesis.

Indicaton:Adjunct diet to reduce LDL, cholesterol, HDL, Adjunct lipid-lowering treatments such as LDL apheresisHeterozygous familial hypercholesterolemiaTo reduce the risk of MI, stoke, angina, or revascularization procedures in pt. w/ multiple risk factor for CAD

Contraindication:In pt. hypersensitive to drug and in those w/ active liver disease or unexplained persistent elevation of transaminase levels.Use cautiously in pt. w/ history of liver dse. or heavy alcohol use.Withhold or stop drug in patients at risk for renal failure; serious acutr condition that suggest myopathy; major surgery; severe acute infection and severe metabolic disorders. Limit use in children to those older than age 9 w/ homozygous familial hypercholesterolemia.

Adverse Effect:CNS: headache, asthenia, insomniaCV: peripheral edemaEENT: pharyngitis, rhinitisGI: abdominal pain, constipation, diarrheaGU:UTIMusculoskeletal: rhabdomyolysisRespiratory: bronchitisSkin: rash

Nursing Considerations:Use only after diet and other nondrug therapies prove ineffective. Pt. should follow a standard low-cholesterol diet before and during therapy.Before treatment, assess pt. for underlying causes for hypercholesterolemia and obtain a baseline a lipid profile.Obtain periodic liver function test results and lipid levels before starting treatment and at 6 and 12 wks. After initiation, or after an increase in dosage and periodically thereafter.Drug may be given as a single dose at any time of day, w/ or w/o food.Watch for signs of myositis

CAPTOPRIL (Capoten)Classification:

Antihypertensive agentDose order/frequency/route:

75 mg 1 tab q 12O Mechanism of Action:

Lower blood pressure by specific inhibition of ACE. This interrupts conversion sequences initiated by rennin that lead to formation of angiotensin II, a potent endogenous vasoconstrictor.Indication:

HypertensionContraindication:

Pregnancy lactationAdverse Reactions:

Hypersensitivity reactions, slight increase in heart rate, first dose hypotension, dizziness, fainting altered taste sensation, weight loss, hyperkalemia, cough, pruritis, photosensitivity and impaired renal function.Nursing implications:

Monitor BP closely following the 1st dose. A sudden exaggerated hypotensive response may occur with in 1-3 hr of 1st dose, especially in those with high BP or on a diuretic.

Advise bed rest and BP monitoring for the 1st 3 hr after initial dose.Patient and Family Education

Report to physician without delay the onset of unexplained fever, easy bruising or bleeding.

Report darkening or crumbling of nail beds.

LACTULOSE (Lilac)

Classification: Laxative

Dose order: 30 cc 2 hs daily

Mechanism of action:

Produces an osmotic pressure effect in colon; resulting distention promotes peristalsis. Also decrease ammonia, probably as a result of bacterial degradation, which lowers the pH colon contents.

Indications:

- Constipation

Contraindication:

- contraindicated in patient with low-galactulose diet

- Use cautiously in patients with diabeted mellitus

Adverse reaction:

GI: abdominal crapms, belching, diarrhea, flatulence, gaseous distention, nausea and vomiting

Nursing Consideration

1. To minimize sweet taste, dilute with water or fruit juice or give with food.

2. Monitor sodium level for hypernatremia, especially when giving in higher doses to treat hepatic encephalopathy

3. Monitor

4. Mental status and potassium levels when giving to pateints with hepatic encephalopathy

5. Replace fluid loss

The Human Brain

The Structure of Artery

The Structure of Neuron

Name of the Patient: Mr. V.E.Date of Discharge: August 17, 2009

MEDICATIONSAdvised the patient to take medication religiously as prescribed by the physician

Phenytoin 100 mg 1 cap BIDPrevacid 30 mg 1 cap once a dayPletaal 50mg 1 tab p.o. ODAtorvastatin Calcium (Lipitor) 10 mg 7 tab P.C. supper

EXERCISE/ENVIRONMENTAL CONCERNS- Encouraged patient’s S.O. to have a well ventilated room and polluted free

environment- Encourage patient’s S.O. to have a calm and quite environmentInstructed the patient’s S.O. to turn the patient into a side-lying position every 2

hours- Advised the patient to ambulate and perform only tolerable exercises

TREATMENT- Reminded the patient’s S.O. the importance of continuing health promotion and

screening practices- Reminded the patient’s S.O. the importance of the following recommendations to prevent further hemorrhagic stroke and keeping follow-up appointments for monitoring of risk factors- Instructed the patient and SO, the importance of following treatment regimen to facilitate the healing process.- Reminded the patient’s S.O. to undergo physical therapy

HEALTH TEACHINGS

- Reminded the patient’s S.O. with information about the causes of hemorrhagic stroke and its possible consequences.

- Instructed the patient’s S.O. to maintain proper hygiene to avoid the risk for infection such as performing perineal care.- Reminded the patient’s S.O. with information about the medical treatment that are implemented, including surgical intervention if warranted.- Reminded the patient’s S.O. the importance of interventions taken to prevent and detect complications (aneurysm precaution, close monitoring of the patient).- Reminded the patient’s S.O. with information that will enable them to cooperate with the care and restrictions required during the acute phase of hemorrhagic stroke- Reminded the patient’s S.O. to maintain sterility or used sterile technique in giving NGT feeding.- Reminded the patient’s S.O. to check the position in giving NGT.- Instructed the patient’s S.O. to prevent aspiration in administering food.