A CASE PRESENTATION ON CEREBROVASCULAR DISEASE INFARCT

Presented to the Faculty of the School of Nursing

Adventist Medical Center College
Brgy. San Miguel, Iligan City

In Partial Fulfillment
of the Requirements for the Degree
BACHELOR OF SCIENCE IN NURSING

Abdullah, Asniah H.

MARCH, 2019
 TABLE OF CONTENTS

I. TITLE PAGE

II. TABLE OF CONTENTS

III. LIST OF TABLES

IV. LIST OF FIGURES

V. OBJECTIVES 1

General Objective

Specific Objectives

VI. DEFINITION OF TERMS 2

VII. INTRODUCTION 3-5

VIII. NURSING HEALTH HISTORY

Vital information 6

History of present health concern 7

Past history 8

Genogram 9

Physical assessment and review of systems 10-15

Gordons assessment 16-17

Diagnostic tests 18-20

IX. NORMAL ANATOMY AND PHYSIOLOGY 21-24

X. PATHOPHYSIOLOGY 25-26

XI. NURSING CARE PLANS 27-33

XII. DISCHARGE PLAN 34-46

XIII. REFERENCES 47
 LIST OF TABLES

1 PHYSICAL ASSESSMENT AND REVIEW OF SYSTEMS 10-15

2 GORDONS ASSESSMENT 16-17

3 NORMAL ANATOMY AND PHYSIOLOGY 21-24

4 NURSING CARE PLAN 27-33

 LIST OF FIGURES

1 GENOGRAM 9

2 PATHOPHYSIOLOGY 25-26
 OBJECTIVES

General Objectives:

At the end of one and a half hour of case presentation, the participants will be able to
learn about the disease process of Cerebrovascular Disease

Specific Objectives:

At the end of one and a half hour of case presentation, the participants will be able to:

1. Relate the health history of the patient to Cerebrovascular Disease;

2. Categorize the physical assessment and review of system involved
Cerebrovascular Diseas;.
3. Numerate at least 5 diagnostic tests related to Cerebrovascular Disease:
4. Discuss the anatomical structure and functions involved in Cerebrovascular
Disease;
5. Summarize the pathophysiology, risk factors and manifestations of
Cerebrovascular Disease;
6. Formulate appropriate nursing process for the client with Cerebrovascular
Disease;.
7. Organize a health education and discharge plan.

1
DEFINITION OF TERMS

2
 INTRODUCTION
An ischemic stroke, also known as cerebrovascular accident or brain attack is
a sudden loss of function resulting from disruption of the blood supply to a part of the
brain. The term brain attack has been used to suggest to health care practitioners and
public that a stroke is an urgent health care issue similar to a heart attack. With the
approval of thrombolytic therapy for the treatment of acute ischemic stroke in 1996
came a revolution in the care of patients after a stroke. Early treatment with
thrombolytic therapy for ischemic stroke results in fewer stroke symptoms and less
loss of function.
Ischemic strokes are subdivided into five different types based on the cause:
large artery thrombotic strokes (20%), small penetrating artery thrombotic strokes
(25%), cardiogenic embolic strokes (20%), cryptogenic strokes (25%), and other.
Large artery thrombotic strokes are caused by atherosclerotic plaques in the large
blood vessels of the brain. Thrombus formation and occlusion at the site of the
atherosclerosis result in ischemia and infarction.
Small penetrating artery thrombotic strokes affect one or more vessels and are
the most common type of ischemic stroke. Small artery thrombotic strokes are also
called lacunar strokes because of the cavity that is created after the death of the
infarcted brain tissue.
Cardiogenic embolic strokes are associated with cardiac dysrhythmias, usually
atrial fibrillation. Embolic strokes can also 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 cerebral artery, resulting in stroke.
Embolic strokes may be prevented by the use of anticoagulant therapy in patients
with atrial fibrillation. The last two classifications of strokes are cryptogenic strokes,
which have no known cause, and strokes from other causes, such as illicit rug use,
coagulopathies, migraine and spontaneous dissection of the carotid or vertebral
arteries.
In an ischemic brain attack, there is a disruption of the cerebral blood flow
due to obstruction of the blood vessel. This disruption in blood flow initiates a
complex series of cellular metabolic events referred to as the ischemic cascade. The
ischemic cascade begins when the cerebral blood flow decreases to less than 25 ml
per 100g of blood per minute. At this point, neurons are no longer able to maintain
aerobic respiration. The mitochondria must then switch to anaerobic respiration,
which generates large amounts of lactic acid, causing a change in the pH. This switch
to the less efficient anaerobic respiration also renders the neuron incapable of of
producing sufficient quantities of ATP to fuel the depolarization process. The
membrane pumps that maintain electrolyte balances begin to fail, and the cells cease
to function.
An ischemic stroke can cause a wide variety of neurologic deficits, depending
on the location of the lesion, the size of the area of inadequate perfusion, and the
amount of collateral blood flow. The patient may present any of the following signs;
numbness of the face, arm or leg especially on one side of the boy, 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. A stroke is an upper motor neuron lesion results in loss of

3
voluntary control over motor movements. Because the upper motor neurons cross, a
disturbance of voluntary motor control on one side of the body may reflect damage to
the upper motor neurons on the opposite side of the brain. The most common motor
dysfunction is hemiplegia, hemiparesis. In the early stage of stroke, the initial clinical
features may be flaccid paralysis and loss or decrease in the deep tendon reflexes.
Other brain functions affected by stroke are language and communication, the
signs are as follow; dysarthria, dysphasia and apraxia. Perception is the ability to
interpret sensation. Stroke can result in visual-perceptual dysfunctions, disturbances
in visual-spatial relations and sensory loss.
To determine the most appropriate treatment for your stroke, your emergency
team needs to evaluate the type of stroke you're having and the areas of your brain
affected by the stroke. They also need to rule out other possible causes of your
symptoms, such as a brain tumor or a drug reaction. Your doctor may use several
tests to determine your risk of stroke, including: Physical examination, Blood tests,
Computerized tomography (CT) scan., Magnetic resonance imaging (MRI), Carotid
ultrasound, Cerebral angiogram and Echocardiogram.

To treat an ischemic stroke, doctors must quickly restore blood flow to your
brain. Emergency treatment with medications. Therapy with clot-busting drugs must
start within 4.5 hours if they are given into the vein — and the sooner, the better.
Quick treatment not only improves your chances of survival but also may reduce
complications. You may be given: Intravenous injection of tissue plasminogen
activator (tPA), Emergency endovascular procedures. Doctors sometimes treat
ischemic strokes with procedures performed directly inside the blocked blood vessel.
These procedures must be performed as soon as possible, depending on features of
the blood clot: Medications delivered directly to the brain. Doctors may insert a long,
thin tube (catheter) through an artery in your groin and thread it to your brain to
deliver tPA directly into the area where the stroke is occurring. This is called intra-
arterial thrombolysis. The time window for this treatment is somewhat longer than for
intravenous tPA, but is still limited. Removing the clot with a stent retriever Other
procedures, to decrease your risk of having another stroke or transient ischemic
attack, your doctor may recommend a procedure to open up an artery that's narrowed
by plaque. Doctors sometimes recommend the following procedures to prevent a
stroke. Options will vary depending on your situation: Carotid endarterectomy
Angioplasty and stents.

Stroke is the Philippines' second leading cause of death. According to the

latest WHO data published in 2017 Stroke Deaths in Philippines reached 87,402 or
14.12% of total deaths. The age adjusted Death Rate is 134.74 per 100,000 of
population ranks Philippines #29 in the world.

4
 VITAL INFORMATION
Code Name: Mr. J
Age: 85 years old
Gender: Male
Civil status: Married
Date of birth: March 3, 1984
Place of birth: Libertad, Misamis Oriental
Race: Filipino
Cultural or ethnic background: Cebuano
Primary language: Bisaya
Secondary language: English, Filipino
Religion: Roman Catholic
Highest educational attainment: College Graduate
Occupation: Pensioner/Retiree Member
Usual health care provider: Attending Physician
Date of admission: January 30, 2019
Source of history: 50% SO, 3% Nurse, 47% Chart
Reasons for seeking health care: Cough and fever
Primary attending physician: Dr. Delorino
Initial impression/diagnosis: Cerebrovascular Accident Infarct

5
HISTORY OF PRESENT ILLNESS

In the year 2014, Mr. J had Transient Ischemic Attack, and was admitted at
Cagayan De Oro Medical Center for 5 days. He was not able to move his lower
extremities when he wake up early in the morning. He felt dizziness associated with
slurring of speech. These symptoms lasted for 6 hours. He was treated and given
with unrecalled medication.

In the year 2016, he was admitted again at Cagayan De Oro Medical Center. He
was diagnosed with mild stroke and manifested paralysis on both lower extremities,
‘dizziness, but, without trouble of speaking. He was able to recover after a week, and
was discharged. A year after, he was suddenly rushed again to the Emergency
Room with the same complaints and diagnosis.

In the year 2018, he was admitted in consecutive months of May, June and July
with the duration of 2 weeks in each admission. He experienced difficulty of
breathing, muscle stiffness, paralysis on both lower extremities, and foot drop. He
had difficulty of swallowing and advised to have Percutaneous Endoscopic
Gastrostomy (PEG). He was not able to speak, disoriented, and bed ridden since that
time. He was diagnosed with Cerebrovascular Accident Infarct and given
maintenance medication such as Pradaxa, Levothyroxine, Spironolactone,
Resovastatin, Lanoxin, Trimetazedine, and Kepra.

3 weeks prior to admission, Mr. J had an onset of productive cough associated

with fever. Worsening of symptoms prompted sought for admission at Cagayan
Medical Center. 6 days after, his family decided to transfer him here in Adventist
Medical Center Iligan because of the reason that he is Seventh-day Adventist.

HISTORY OF PAST ILLNESS

Mr. J was admitted for 1 week when he was still college student. He was
diagnosed with pneumonia and found out that he has fluid in his left lung. At the age
of 81, his pneumonia recurred.

In the year 2004, he was diagnosed with Hypothyroidism and was given
maintenance medication which is levothyroxine. At the age of 69, he had head injury
which prompted to rush him in to Emergency Room.

He was fond of eating foods high in fat like beef products and fast foods. He
was an inactive for several years because of previous work.

6
Maternal Paternal

PATIENT
LEGEND:

(FEMALE) (HYPERTENSION) (ALIVE) (UNKNOWN) PNEUMOINIA

(MALE) (PUD) ( DECEASED) (DM)

7
 PHYSICAL ASSESSMENT AND REVIEW OF SYSTEMS

AREAS DAY 1 DAY 2 PROBLEM

ASSESSE IDENTIFIED
D

General  Subjective Subjective findings: (Not

health findings: applicable)
survey (Not Applicable)

Objective findings: Objective findings:

-Vital signs: -Vital signs
T: 35.6- 36.2 C T: 35.8-36 C
BP: 90/70-100/60 mmHg BP: 85/60- 100/60 mmHg
PR: 87-114 bpm PR: 98-100 bpm
RR: 21-29 bpm RR: 21-25 bpm
O2sat: 95- 98% O2sat: 93-97% Ineffective
GCS:7/15 GCS: 7/15 breathing pattern

o O2 inhalation via nasal o O2 inhalation @2L/min via

cannula at 2L/ min nasal cannula
o Venoclysis mainline on o Venoclysis mainline on
left metacarpal vein left metacarpal vein PNSS
PNSS 1 L @10cc/hour 1 L @10cc/hour via
via infusion pump infusion pump
o c side drip dopamine 20 o c side rip dopamine 20 cc/
cc/ hour (decreased 1 cc hour (decreased 1 cc per
per hour) hour) Altered cerebral
o c meds side drip o c meds side drip dopamine perfusion
dopamine 100 ml, 100 ml, levofloxacin 250
levofloxacin 250 ml, ml, meropenem 50 ml
meropenem 50 ml o c condom catheter, urinary
o c condom catheter, output 500 cc am shift Constipation
urinary output 1250 cc o No BM since admission
am shift o c PEG tube attached
o c PEG tube attached
o No BM since admission

(+) Body weakness (+) Body weakness Fatigue

(+) Weak appearance (+) Weak appearance
(+) Productive purulent (+) Productive purulent cough Ineffective
cough (+) Rigid abdomen airway clearance
(+) Rigid abdomen (+) Generalized edema
(+) Generalized edema including scrotal area Constipation
including scrotal area (+) Crackles all over both
(+) Crackles all over both lungs Fluid volume
lungs (+)Confusion and excess
(+)Confusion and disorientation
disorientation (+) Paralysis on both lower Ineffective
(+) Quadriplegia extremities breathing pattern
(+) Aphasia (+) Aphasia
(+) Pupils equal but slow (+) Pupils equal but slow Impaired
reaction to light and reaction to light and mobility
accommodation accommodation

8
 (+) Watery eyes (+) Watery eyes Altered cerebral
(+) Drooping eyelid (+) Drooping eyelid perfusion
(+) Dry oral mucosa and (+) Dry oral mucosa and lips
lips (+) Senile skin Impaired verbal
(+) Senile skin ( +) Decreased response to communication
( +) Decreased response to pain and sense of touch
pain and sense of touch Activity
intolerance

Impaired skin
integrity

Disturbed body
image

Integument Subjective findings: Subjective findings:

ary system (Not Applicable) (Not applicable)

Ineffective
tissue perfusion

Objective findings: Objective findings: Impaired skin

o Generalized edema o Generalized edema integrity
o Poor skin turgor o Poor skin turgor
o Senile skin o Senile skin Fluid volume
o Dry oral mucosa and o Dry oral mucosa and lips excess
lips Pale nailbeds
o Pale nailbeds

HEENT Subjective findings: Subjective findings:

a) Hea (Not Applicable) (Not applicable)
d Fatigue
and Objective findings: Objective findings:
face (+) Weak in appearance Altered motor

9
 b) Eye (+) Equal, but slow reaction +) Weak in appearance function
s to light and accommodation (+) Equal, but slow reaction to
c) Ear (+)Watery eyes light and accommodation Ineffective
s (+)Drooping eyelids\ (+)Watery eyes airway clearance
d) Nos (+)Productive purulent (+)Drooping eyelids\
e cough (+)Productive purulent cough Ineffective
e) Ora (+) difficulty of swallowing (+) difficulty of swallowing verbal
l (+) Not able to speak (+) Not able to speak communication
Cav (+)Dry oral mucosa and (+)Dry oral mucosa and lips
ity lips Dehydration

Lab result:
(+) Positive bacteria on
sputum exam

Neck Subjective findings: Subjective findings: No problem

(Not Applicable) (Not applicable) Identified

Objective findings:
Objective findings:
(-) stillness (-)stillness
(-) lumps (-) lumps
(-) vein engorgement (-) vein engorgement

Respirator Subjective findings: Subjective findings:

y system o Not applicable (Not applicable)
Ineffective
Objective findings: Objective findings: airway clearance
o RR: 21-29
o RR: 21-29 Ineffective
(+) Dyspneic (+) Dyspneic breathing pattern
(+) Crackles all over both (+) Crackles all over both
lungs lungs
(+) Productive purulent (+) Productive purulent cough
cough
(+)use of accessory Lab result:
muscles noted
Lab result: o X-Ray
Impression: Bilateral
o X-Ray pneumonia, left with
Impression: Bilateral consolidation of the left
pneumonia, left with upper lobe
consolidation of the left Minimal pleural effusion
upper lobe with pleural thickening on
Minimal pleural the left
effusion with pleural Superimposed pulmonary
thickening on the left edema
Superimposed Cardiomegaly
pulmonary edema
Cardiomegaly
o Ultrasound chest
Non-loculated RIGHT

10
 pleural fluid, with
estimated volume of
350 cc
The left hemithorax
showed loculated
pleural fluid collection
with estimated volume
of 294cc ( left upper
chest) with fine
loculations
171cc ( left lower
chest) fibrin-rich
loculated fluid

Cardiovasc Subjective findings: Subjective findings:

ular system (not applicable) (not applicable)
Objective findings: Objective findings:
BP: 90/70-100/60 mmHg BP: 85/60- 100/60 mmHg Ineffective
PR: 87-114 bpm PR: 98-100 bpm tissue perfusion

Lab result: Lab result:

o Lab result: o Lab result:

o X-Ray o X-Ray
Impression: Bilateral Impression: Bilateral
pneumonia, left with pneumonia, left with
consolidation of the left consolidation of the left
upper lobe upper lobe -
Minimal pleural Minimal pleural effusion
effusion with pleural with pleural thickening on
thickening on the left the left
Superimposed Superimposed pulmonary
pulmonary edema edema
Cardiomegaly Cardiomegaly

o ECG showed o ECG showed

cardiomegaly cardiomegaly

Breast and Not assessed Not assessed

Axilla
Gastrointes Subjective findings: Subjective findings:
tinal Not applicable (Not applicable)
system and Objective findings: Constipation
the
abdomen Objective findings: o PEG tube attached Imbalanced
o PEG tube attached o No BM since admission Nutrition
o No BM since admission (+) Rigid abdomen
(+) Rigid abdomen
Lab result:
Lab result: Total protein, albumin globulin
Total protein, albumin
globulin Protein: 55.9( 60-82g/L

11
 Albumin: 22 (35-50 g/l
Protein: 55.9( 60-82g/L Globulin 33.9 ( 20/30 g/L)
Albumin: 22 (35-50 g/l
Globulin 33.9 ( 20/30 g/L)

Genitourin Subjective findings: Subjective findings:

ary/ (Not Applicable)
Reproducti
ve system
Objective findings: o Objective findings: c Fluid volume
o c condom catheter, condom catheter, urine excess
urine output of 1250 cc output of 500 cc am shift
am shift (+) edema on scrotal area
(+) edema on scrotal area

Musculosk Subjective findings: Subjective findings: Activity

eletal (Not Applicable) (not applicable0 intolerance
system Objective findings:
o Venoclysis mainline on Impaired
Objective findings: left metacarpal vein 1L physical
o Venoclysis mainline on PNSS @ 10 cc/hour via mobility
left metacarpal vein 1L infusion pump
PNSS @ 10 cc/hour via (+)Body weakness
infusion pump o (+) Paralysis on both lower
(+)Body weakness extremities
(+) Paralysis on both lower
extremities
Neurologic Subjective findings: Subjective findings:
system (Not Applicable (Not applicable)

Objective findings: Altered cerebral

perfusion
Objective findings: (+) Confusion
(+) Confusion (+)Disorientation
(+)Disorientation o GCS 7/15. Altered motor
(+)Dysphagia function
(+)Aphasia Laboratory result:

o GCS 7/15. CT Scan

Impression:
Laboratory result: SUBACUTE TO CHRONIC
INFARCTIVE CHANGES IN
CT Scan LEFT POSTERIOR
Impression: PARIETAL-OCCIPITAL
SUBACUTE TO LOBES AND LEFT
CHRONIC INFARCTIVE CEREBELLUM, AS
CHANGES IN LEFT DECRIBED
POSTERIOR PARIETAL- LACUNAR INFARCT IN
OCCIPITAL LOBES AND LEFT THALAMUS
LEFT CEREBELLUM, AS
DECRIBED
LACUNAR INFARCT IN

12
 LEFT THALAMUS
Lymphatic/ Subjective findings: Subjective findings: Risk for
Hematologi (Not Applicable) decreased
c system cardiac output

Objective findings:
(Not Applicable)
Lab result: Ineffective
tissue perfusion
Lab result: COMPLETE BLOOD
COUNT
COMPLETE BLOOD
COUNT RBC: 3.3 (4-6 x 10 12/L)
HEMATOCRIT: 0.30(0.37-
RBC: 3.3 (4-6 x 10 12/L) 0.47)
HEMATOCRIT:
0.30(0.37-0.47)

Endocrine Subjective findings: Subjective findings:

system (Not Applicable)

Constipation
Objective findings: Objective findings:
(Not Applicable) (Not Applicable) Fatigue

(+) Body weakness (+) Body weakness

(+) Dry skin (+) Dry skin
(+)Brittle nails (+)Brittle nails

Lab result: Lab result:

FT3: 1.97 (0.4-.0.9 mu/L) FT3: 1.97 (0.4-.0.9 mu/L)

FT4: 20.05 (9-25 pmol.L FT4: 20.05 (9-25 pmol.L
TSH: 2.990 (3.5-7.8 TSH: 2.990 (3.5-7.8 pmol/L)
pmol/L)

13
 GORDONS ASSESSMENT

BEFORE HOSPITALIZATION DURING HOSPITALIZATION

NUTRITIONAL/ METABOLIC PATTERN
 Mr. J was fond of eating foods high in fat and  PEG TUBE FEEDING
cholesterol like beef steak, ginataang baka and
manok before he had an ischemic attack
 He started to have PEG tube feeding last July, 2018

ELIMINATION PATTERN
 The SO states he defecates once a day usually every  Condom catheter with urine output of 1250 cc
morning with the characteristic of sem formed stool in day 1, 500cc in day 2
without difficulty and use of laxatives.  No BM since admission
 The client urinate 3x a day or more varying in his
fluid, with no difficulty in voiding.
EXERCISE AND ACTIVITY PATTERN
 He is fond of playing tennis since in his middle  Confine to bed
adulthood until 65 years old
 After retiring from his work, he stayed at home
all the time
 He was bebridden since July 2018

SLEEP/ REST PATTERN

 He usually sleeps early around 8-9 in the evening  He had difficulty of sleeping during my
and wakes 6 am in the morning. The client has 9 shift
hours of sleep every day without the any use
sleeping aids.
ALCOHOL AND STREET DRUGS
 Confine to bed
 No vices and used of any drugs
ENVIRONMENTAL HAZARDS
 They lives in subdivision, 1km away from the  Confine to bed
highwayThe patient stated that their 
surroundings are well sanitized and safe.
INTIMATE PARTNER VIOLENCE
 He never mistreated his wife or forced to do  His wife takes good care of him
something that does not satisfy them both. In  They are so sweet, with the endearment of
fact he takes good care of him so much. “Daddy, mommy”
OCCUPATIONAL HEALTH
 He used to work as secretary and administrator  Confine to bed
at Mountain View College
 He is a pastor
 Pensioner/ Retiree
COGNITIVE AND PERCEPTUAL PATTERN  Confusion
 Patient wears glasses.  Disorientation
 He had his eye examined with a grade of 100.  Aphasia
 GCS of 7/15
SELF- RELATIONSHIP PATTERN  Confine to bed
 Bedridden since July 2018. 
COPING STRESS MANAGEMENT PATTERN
 Seeking to his family and God
 Anxiety

14
 COMPLETE BLOOD COUNT AND PLATELET

TEST RESULT NORMAL VALUE NURSING

January 30,2019 CONSIDERATION
RED BLOOD CELLS 3.10 4-6x10 12/L
HEMATOCRIT 0.30 0.40-.54
HEMOGLOBIN 110.0 130-160 g/L

WBC 7.12 5-10x10 9/L

LYMPHOCYTES 0.03 0.25-0.35
SEGMENTERS 0.94 0.50-0.65
STABS 0 0.05-0.10
MONOCYTES 0.03 0.03-0.07
EOSINOPHILS 0 0.01-0.3
BASOPHILS 0 0-0.01
PLATELET COUNT 263 140-450x 10 9/L

POTASSIUM AND SODIUM

RESULT NORMAL NURSING

January 30,2019 February 05,2019 VALUE CONSIDERATION

POTASSSIUM 5.50 4.35 3.5-5.3 mmol/L

SODIUM 110.4 135-148mmol/L

BUN AND CREATININE

RESULT NORMAL VALUE NURSING
February 05,2019 CONSIDERATION
BUN 26.33 2.5-7.2mmol/L
CREATININE 351.49 71-115mmol/L

SPECIMEN ORGANISM COLONY COUNT NURSING

ISOLATED CONSIDERATION
SPUTUM PSUDOMONAS MODERATE
SPP. GROWTH

EXAMINATION RESULT NORMAL VALUE NURSING

Jan.30,2019 CONSIDERATION
HEMOGLUCOTEST 96 70-110mg%
CALCIUM 2.16 2.2-2.7mmol/L
MAGNESIUM 0.70 0.73-1.06mmol/L
CREATININE 278.04 71-115umol/L

15
 TPAG(TOT,PROTEIN,ALB/GLOB RATIO)
EXAMINATION RESULT NORMAL NURSING
Jan.31,2019 VALUE CONSIDERATION
TOTAP PROTEIN 55.9 60-82g/L
ALBUMIN (A/G) 22.0 35-50g/L
GLOBULIN(A/G) 33.9 20-30g/L

FASTING BLOOD SUGAR LIPID PROFILE

TEST NORMAL RANGE RESULT NURSING
CONSIDERATION
CHOLESTEROL 0-200 68.5mg/dL
TRIGLYCERIDES 0-150 58.7/dL
Direct HCL 40-60 39.90mg/dL
LDL 60-180 16.9mg/dL

ULTRASOUND-WHOLE ABDOMEN
February 04,2019
Impression Pre Nursing Responsibilities
 Non-loculated Right Pleural  Eexplain procedure
fluid, with estimated vol of 350  Tell pt to relax
cc  Shave area of the placement if body hair is present
 The left hemothorax showed  Remove any jewelries in the body
loculated pleurak fluid  Tell pt not to move while procedure is ongoing
collection with estimated
volume of 294cc (left lower
chest) with fine loculations and
171cc(left lower chest) fibrin-
rich, localated fluid

X-RAY OF THE CHEST

February 04,2019
Impression
 Resolving bilateral pneumonia with
regression of the bilateral pleural
effusion
 Left pleural thickening with
persistent inhomogenous
opacification of the left upper lung
 Cardiomegaly
 Atherosclerotic aorta
Pre Nursing Responsibilities
 Eexplain procedure
 Tell pt to relax
 Shave area of the placement if body hair is present
 Remove any jewelries in the body
 Tell pt not to move while procedure is ongoing

16
 CT SCAN
JANUARY 30,2019

Impression Pre Nursing Responsibilities

 Subacute to chronic infarctive
changes in the left posterior parietal-
occipital lobes and left cerebellum, as
described
 Lacunar infarctive in the left
thalamus
 Eexplain procedure
 Tell pt to relax
 Shave area of the placement if body hair is present
 Remove any jewelries in the body
 Tell pt not to move while procedure is ongoing

ARTERIAL BLOOD GAS ANALYSIS

17
 NORMAL ANATOMY AND PHYSIOLOGY
Anatomical Structure/s Description and Functions
1. Brain  Responsible for a variety of functions including
 Forebrain receiving and processing sensory information,
thinking, perceiving, producing and understanding
 Midbrain language, and controlling motor function.
 The midbrain is the portion of the brainstem that
 Hindbrain connects the hindbrain and the forebrain. This region
of the brain is involved in auditory and visual
responses as well as motor function.
 These regions assists in maintaining balance and
equilibrium, movement coordination, and the
conduction of sensory information.
2. Basal ganglia  Involved in cognition and voluntary movement
3. Brain stem  Relays information between the peripheral nerves
and spinal cord to the upper parts of the brain

 Consists of the midbrain, medulla oblongata, and the

pons

4. Broca’s area  Speech production

 Understanding language

5. Cerebellum  Controls movement coordination

 Maintains balance and equilibrium

6. Cerebral Cortex  Outer portion (1.5mm to 5mm) of the cerebrum

 Receives and processes sensory information

 Divided into cerebral cortex lobes

 Frontal Lobes -involved with decision-making,

problem solving, and planning

 Occipital Lobes -involved with vision and color

recognition

 Parietal Lobes - receives and processes sensory

information

 Temporal Lobes - involved with emotional

responses, memory, and speech

7. Cerebrum  Largest portion of the brain

 Consists of folded bulges called gyri that create deep

furrows

8. Cranial nerves  Twelve pairs of nerves that originate in the brain,

exit the skull, and lead to the head, neck and torso

18
9. Hypothalamus  Directs a multitude of important functions such as
body temperature, hunger, and homeostasis
10. Thalamus  mass of grey matter cells that relay sensory signals
to and from the spinal cord and the cerebrum
11. Neurons  the fundamental unit of the nervous system.
The basic purpose of a neuron is to receive
incoming information and, based upon that
information, send a signal to other neurons,
muscles, or glands.

19
 ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

Subjective: Ineffective breathing patter Short term: After 5-6 hours Independent: The patient was able to
“Maglisud jud na siyag ginhawa” related to trachea-bronchial of nursing intervention, the 1. Assess respiratory rate  Respiratory rate and rhythm establish normal/effective
As verbalized by the wife obstruction secondary to client will be able to and depth by listening to changes are early warning respiratory pattern as
pleural effusion as demonstrate appropriate lung sounds signs of impending evidenced by absence of
Objective: evidenced by dyspnea coping behavior like proper respiratory difficulties hypoxia, normal skin color
T: 35.8-36 C breathing and coughing 2. Position client with  This is good for lung
BP: 85/60- 100/60 mmHg proper body alignment excursion and chest
PR: 98-100 bpm Long term: (semi-fowler’s position” expansion
RR: 21-25 bpm 3. Encourage sustained  These promote deep
O2sat: 93-97% After 2 nights of nursing deep breaths by inspiration
GCS: 7/15 interventions the client was emphasizing slow
able to establish a normal or inhalation, holding end
(+) Dyspneic effective respiratory pattern inspiration)
(+) Crackles all over both lungs as evidenced by absence of 4. Note muscles used for  These signify an increase
(+) Productive purulent cough hypoxia, normal skin color breathing and work of breathing
(+) Use of accessory muscles retractions/flaring of
noted nostrils
5. Pace and schedule  These prevents dyspnea
Oxygen via nasal cannula @ activities providing resulting from fatigue
2L/min adequate rest periods

Lab result:

o X-Ray Collaborative:
Impression: Bilateral 1. Administer  To support meet desired
pneumonia, left with supplemental oxygen oxygen demand
consolidation of the left upper @ 2L/min
lobe 2. Administer

20
 Minimal pleural effusion with medication as
pleural thickening on the left prescribed
Superimposed pulmonary 3. Thoracentesis
edema
Cardiomegaly
o Ultrasound chest
Non-loculated RIGHT pleural
fluid, with estimated volume of
350 cc
The left hemithorax showed
loculated pleural fluid
collection with estimated
volume of 294cc ( left upper
chest) with fine loculations
171cc ( left lower chest)
fibrin-rich loculated fluid

21
 ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION
“Nagpa admit name kay Ineffective airway Short term: Independent:
grabe na kayo iyang ubo” clearance related to The client was able to
increased production of After 5-6 hours of nursing 1. Note chest movements: Use  May indicate in response maintain patent airway as
Objective: bronchial secretions interventions the patient of accessory muscles during to ineffective respiration evidenced by absence of:
secondary to fluid shift will be able to display respiration  Less production of
T: 35.8-36 C to extravascular decrease amount of 2. Auscultate breath sounds:  Crackles indicate secretions
BP: 85/60- 100/60 mmHg compartment secretions noted areas with presence of accumulation of secretions  Restlessness are
PR: 98-100 bpm adventious breath sounds and inability to clear alleviated
RR: 21-25 bpm Long term: airways  No use of accessory
O2sat: 93-97% 3. Documented respiratory muscles when
GCS: 7/15 After 2-3 days of nursing secretions: character and  Expectorations may be breathing
interventions the patient amount of sputum different when secretions
will be able to maintain a 4. Maintained patent on are very thick
(+) Productive purulent patent airway as evidence moderate high back rest
cough by:  Positions helps maximize
(+) Crackles all over the  Independence from lung expansion
lungs oxygen 5. Checked for obstructions:
(+) Use of accessory muscles  Normal respiration accumulation of secretions  Maintain adequate airway
noted as evidenced by patency
(+) Restless absence by dyspnea Dependent:
1. Administer supplemental  Support meet desired
oxygen as indicated, @ oxygen demand
o X-Ray 2L/min
Impression: Bilateral 2. Suctioned patient limited to  Duration should be limited
pneumonia, left with 15 sec duration to reduce hazard of
consolidation of the left hypoxia ,damage airway
upper lobe mucosa and impair cilia
Minimal pleural effusion action

22
 with pleural thickening 3. Administer medications as
on the left prescribed
Superimposed pulmonary
edema
Cardiomegaly
o Ultrasound chest
Non-loculated RIGHT
pleural fluid, with
estimated volume of 350
cc
The left hemithorax
showed loculated pleural
fluid collection with
estimated volume of
294cc ( left upper chest)
with fine loculations
171cc ( left lower chest)
fibrin-rich loculated fluid

23
 ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

“Dili na siya mo response Altered cerebral perfusion Short term: Independent:

kong estoryahan nimo siya” related to interruption of the After 5-6 hours of nursing
as verbalized by the wife blood flow secondary to CVA interventions the patient 1. Monitor vital signs  To have baseline data,
will be able to display change in neurologic
Objective: decrease signs of status
ineffective tissue perfusion 2. Elevate head of the bed  Promote circulation
T: 35.8-36 C as evidence by gradual to high back rest
BP: 85/60- 100/60 mmHg movement of vital signs 3. Promote quiet, restful  Encourages
PR: 98-100 bpm atmosphere compliance to
RR: 21-25 bpm Long term: therapeutic regimen
O2sat: 93-97%
GCS: 7/15 After 2-3 days of nursing
Eye opening response: interventions the patient Dependent:
Opens to pain, not applied to will be able to gradually 1. Administer
face= 2 improve tissue perfusion as supplemental
Verbal response: ‘ evidenced by good oxygen as
None: 1 capillary refill and pink indicated
Motor response: conjunctiva 2. Administer
Withdraws from pain: 4 medication as
(+)Quadriplegia indicated
(+) Aphasia
(+)Bed ridden
(+) Difficulty of swallowing
(+) Pupil equal, But slow
reaction to light

24
(+)Confusion
(+)Disorientation
(+) Slowed capillary refill:
2> seconds

Lab test:
CT Scan impression:
 Subacute to chronic
infarctive changes in
the left posterior
parietal-occipital
lobes and left
cerebellum, as
described
 Lacunar infarctive in
the left thalamus

25
 ASSESSMENT
Subjective:
“ Atong July 2018 pa na siya
nagsugod og dili kalakaw” as
verbalized by the wife
Objective:
(+) Bed ridden
(+) Quadriplegia
(+)Muscle atrophy
(+)foot drop
(+) Powerlessness
(+)Fatigue
Lab test:
CT Scan impression:
 Subacute to chronic
infarctive changes in
the left posterior
parietal-occipital
lobes and left
cerebellum, as
described
 Lacunar infarctive in
the left thalamus
NURSING DIAGNOSIS PLANNING
Impaired physical mobility Short term:
related to neuromuscular After 5-6 hours of nursing
damage secondary to CVA interventions the patient will
infart be able to participate in
activities necessary for him.
Long term:
After 2-3 days of nursing
interventions the patient will
be able to improve strength
and functions of the affected
part
INTERVENTIONS RATIONALE EVALUATION
STO: The patient was able to
1. Provide safety measures  To prevent occurrence of maintain position of
including fall prevention injury function and skin integrity
2. Frequent turning of the  Prevent bed sores as evidenced by absence of
patient q 2 hours \ contractures, foot drop and
3. Assess functional ability  Identifies strength or decubitus
deficiencies and may
provide information
regarding recovery
4. Provide good skin care
and gently massage  Reduces risk for
pressure points after each decreased perfusion and
position change ischemia to prevent skin
irritation/breakdown
5. Perform active and
passive ROM  Maintains mobility and
function of joints,
functional alignment od
extremities , minimizes
muscle atrophy, promotes
circulation and reduces
LTO venous stasis
1. Administer oxygen as
prescribed
2. Administer meds as
indicated
26
27
 ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION
Subjective: Volume fluid excess Short term: Independent:
“Sauna rana iyang hupong” as related to inability of the After 8 hours of nursing 1. Monitor and record vital  Obtain baseline data
verbalized by the wife kidney to maintain body intervention, the patient signs
fluid balance will be able to achieve at 2. Restrict fluids  Prevent further fluid
Objective: least 1 L of urine output retention
(+) Generalized edema 3. Change position client
including scrotal area timely, q 2 hours  Prevent pressure ulcers
(+) Dyspnea
(+) Changes in mental status Long term: 4. Evaluate mental status  May indicate cerebral
(+)Weight gain After 2-3 days of nursing edema
(+) Oliguria intervention the patient will
be able to stabilize fluid Dependent:
o X-Ray volume as evidenced by 1. Administer medication
Impression: Bilateral balance I and O, normal as ordered
pneumonia, left with vital signs, and free from
consolidation of the left edema
upper lobe
Minimal pleural effusion
with pleural thickening on
the left
Superimposed pulmonary
edema
Cardiomegaly
o Ultrasound chest
Non-loculated RIGHT
pleural fluid, with
estimated volume of 350
cc
The left hemithorax
showed loculated pleural
fluid collection with
estimated volume of

28
 294cc ( left upper chest)
with fine loculations
171cc ( left lower chest)
fibrin-rich loculated fluid

29
Modifiable factor: Non-modiafiable factor:

 Hypertension (Diagnosed since 2014)  Age (85 years old)

 Sedentary lifestyle (Physical  Gender(male)
inactivity)  Family history
 Nutrition diet ( Increased high fat)  Race (Asian)
 Type A personality (Stress)
 Hyperlipidemia

30
 DISCHARGE PLAN
A. OBJECTIVE
1. Summarize a simple and productive health education plan;
2. Adhere prescribed medications for health maintenance and resistance;
3. Promote a health lifestyle, maximize the level of health ;
4. Gains knowledge in managing the condition; and
5. Maintain and ensure adequate intake for nourishment

B. METHOD
Medications
DRUG STUDY
Generic Classific Indication Mechanism of Route/ Adverse Reaction Drug to Drug Patient teaching
Name ation Action Freque Interaction
ncy/Do
sage
Aspirin Analgesi  mild to Analgesics and 80mg/t  Acute aspirin toxicity:  increased risk of  take extra
c moderate antirheumatic ab, 1tab respiratory alkalosis, bleeding with oral precautions to
pain effects are PO OD hyperpnea, anticougulants, keep this drug
 fever attributable to tachycardia,hemorrhage,e heparin out of the reach
 inflammator aspirin’s to xcitement,confusion,asteri  increased risk of of children; this
y inhibit the xis,pulmunoryedema,seizu GI ulceration with drug can be
conditions- synthesis of rers,tetany,metabolic steroids, very dangerous
rheumatic prostaglandins, acidosis, fever, coma ,CV phenylbutazone, for children

31
 fever, important collapse, renal and alcohol, NSAIDS  use the drug only
rheumatic mediators of respiratory failure  increased serum as suggested;
arthritis, inflammation.  Aspirin intolerance: salicylate levels avoid over dose.
osteoarthriti exacerbation of due to decreased Avoid the use of
s, juvenile bronchospasm, rhinitis salicylate other over-the-
rheumatoid (with nasal polyps, excretion with counter drugs
arthritis, asthma, rhinitis) urine acidifies contain aspirin,
spondyloart  GI: nausea, dyspepsia, (ammonium and serious
hropathies hearburn, chloride, ascorbic overdose can
epigastricdiscomfort, acid, methionine) occur.
anorexia, hepatoxicity  Take the
 Hematologic: occult drug
blood loss, hemostatic with
defects food or
 Hypersensitivity: after
anaphylactoid reaction to meals if
anaphylactic shock GI upset
occurs.
Isosorbide Antiangi  Dinitrate: Relaxes vascular 30mg/t  CNS: headache,  Increased systolic  Place
mononitrat nal treatment smooth muscle ab, 2tab apprehension, BP and decreased sublingu
e and with a resultant BID restlessness, weakness, antianginal effects al tablets
prevention decrease in vertigo, dezziness, if taken under
of angina venous return faintness concurrently with your
pectoris and decrease in  CV: tachycardia, ergot alkalosis tongue or
 Mononitrate arterial BP, retrosternal discomfort, in your
: prevention which reduces palpitations, hypotension, cheek;
of angina left ventricular syncope, collapse do not
pectoris; workload and  GI: nausea, vomiting, chew,
treatment of decrease incontinence of feces, swallow,
angina myocardial of abdominal pain, diarrhea, or crush
oxygen the

32
 pectoris consumption. ulcer tablet.
(mmonoket)  GU: dysuria, impotence, Take the
 Unlabeled urinary frequency isosorbid
use e before
(dinitrate); chest
use with pain
hydralazine begins,
in black when
patients activities
with or
advanced situation
heart al may
failure; precipitat
acute angle- e an
closure attack.
glaucoma in  Keep
emergent life-
situations; support
achalasia equipme
nt readily
available
if
overdose
occurs or
cardiac
condition
s
worsens.
Atorvastati Antihype  Adjunct to Inhibits HMG- 80mg/t  CNS: headache, asthenia  Increased digoxin  Take this drug
n rlipidemi diet in CoA reductase, ab, 1tab  GI: flatulence, dyspepsia, levels with once a day, at
c treatment of the enzyme that OD q heartburn, liver failure possible toxicity if about the same

33
elevated catalyzes the HS  Respiratory: sinusitis, taken together, time each day,
total first step in the pharyngitis monitor digoxin preferably in the
cholesterol, cholesterol level evening; may be
serem synthesis  Increased estrogen taken with food.
triglycerides pathway, levels with Do not drink
, and LDL resulting in a hormonal grapefruit juice
cholesterol decrease in contraceptives; while taking this
and to serum monitor patients drug
increase cholesterol, on this  Institute
HDL-C in serum LDLs combination. appropriate
patients (associated with dietary changes
with increased risk of  Arrange to have
primary CAD), and periodic blood
hypercholes increased serum test while you are
terol (types HDLs taking this drug.
II and IIb) (associated with
and mixed deceased risk of
dyslipidemi CAD); increases
a and hepatic LDL
primary recapture sites,
dysbetalipo enhances
proteinemia, reuptake and
whose catabolism of
response to LDL; lowers
dietary triglyceride
restriction levels.
of saturated
fat and
cholesterol
and other
non

34
 pharmacolo
gic measure
has not been
adequate.
Enalapril Ace  Hypertensio Inhibits 5mg/ta  CNS: dizziness, fatigue,  Allopurinol:  Assess for rapid
inihibitor n conversion of b, 1 tab headache, insomnia, increased risk of blood pressure
angiotensin I to BID drowsiness, vertigo, hypersensitivity drop leading to
angiotensin II, a asthenia, paresthesia, reaction cardiovascular
potent ataxia, confusion,  Antacids: collapse,
vasoconstrictor; depression, nervousness, decreased enalapril especially when
inactivates cerebrovascular accident absorption giving with
bradykinin and  CV: orthostatic Cyclosporine, diuretics
prostaglandins. hypotension, palpitations, indomethacin,  In patient with
Also increases angina pectoris, potassiumsparing renal
plasma renin and tachycardia, peripheral diuretics, insufficiency or
potassium levels edema, arrhythmias, potassium renal artery
and reduces cardiac arrest supplements: stenosis, monitor
aldosterone  EENT: sinusitis hyperkalemia for worsening
levels, resulting  GI: nausea, vomiting, Digoxin, lithium: renal function.
in systemic constipation, dyspepsia, increased blood  After initial dose,
vasodilation. abdominal pain, dry levels of these observe patient
mouth, pancreatitis drugs, possible closely for at least
toxicity Diuretics, 2 hours until
nitrates, other blood pressure
antihypertensives, has stabilized.
phenothiazines: Then continue to
additive observe for
hypotension additional hour.
Nonsteroidal anti-
inflammatory
drugs: decreased

35
 antihypertensive
response
Rifampin:
decreased enalapril
efficacy
Carvedilol Antihype Hypertension Blocks 6-  CNS: dizziness, fatigue,  Antihypertensives:  Watch for signs
rtensive stimulation of 25mg/t anxiety, depression, additive and symptoms of
cardiac beta1- ab, 1tab insomnia, memory loss, hypotension hypersensitivity
adrenergic OD q nightmares, headache, Calcium channel reaction.
receptor sites HS pain blockers, general  Assess baseline
and pulmonary  CV: orthostatic anesthetics, I.V. CBC and kidney
beta2-adrenergic hypotension, peripheral phenytoin: and liver function
receptor sites. vasoconstriction, angina additive test results.
Shows intrinsic pectoris, chest pain, myocardial  Monitor vital
sympathomimeti hypertension, bradycardia, depression signs (especially
c activity, heart failure,  Cimetidine: blood pressure),
causing slowing atrioventricular block increased ECG, and
of heart rate,  EENT: blurred or carvedilol toxicity exercise
decreased abnormal vision, dry eyes,  Clonidine: tolerance. Drug
myocardial stuffy nose, rhinitis, increased may alter cardiac
excitability, sinusitis, pharyngitis hypotension and output and cause
reduced cardiac  GI: nausea, diarrhea, bradycardia, ineffective airway
output, and constipation GU: urinary exaggerated clearance.
decreased renin tract infection, hematuria, withdrawal  Weigh patient
release from albuminuria, decreased phenomenon daily and measure
kidney libido, erectile fluid intake and
dysfunction,renal output to detect
dysfunction fluid retention.
 Measure blood
glucose regularly

36
 if patient has
diabetes mellitus.
Drug may mask
signs and
symptoms of
hypoglycemia.
 ●Instruct patient
to take drug with
food exactly as
prescribed.
 Tell patient to
take extended-
release capsule in
the morning with
food, to swallow
capsule whole,
and not to chew,
crush, or divide
its contents.
Mucosta Antacid  Peptic ulcer Rebamipide is a 1 tab  CNS: dizziness, headache,  Ampicillin,  Assess vital signs.
 Gastritis mucosal 3x/day asthenia cyanocobalamin,  Check for
protective agent  GI: nausea, vomiting, iron salts, abdominal pain,
and is postulated diarrhea, constipation, ketoconazole: emesis, diarrhea,
to increase abdominal pain reduced absorption or constipation.
gastric blood  Metabolic: of these drugs  Evaluate fluid
flow,prostagland hypomagnesemia Clarithromycin: intake and output.
in biosynthesis  Musculoskeletal: back increased  Watch for
and decrease free pain; fractures of hip, omeprazole blood elevated liver
oxygen radicals. wrist, spine (with long- level function test
term daily use)  Clopidogrel: results (rare).

37
 Respiratory: cough, upper diminished  Monitor
respiratory tract infection antiplatelet activity magnesium level
 Skin:rash Diazepam, before starting
phenytoin, drug and
warfarin: periodically
prolonged thereafter in
elimination and patients expected
increased effects to be on long-
of these drugs term treatment or
 Digoxin: increased who take proton
digoxin absorption pump inhibitors
and blood level, with other drugs
possible digoxin such as digoxin or
toxicity Drugs drugs that may
metabolized by cause
CYP450 system: hypomagnesemia.
competitive
metabolism
Methotrexate:
increased
methotrexate
serum level
 Penicillins: serious
and occasionally
fatal
hypersensitivity
reactions including
anaphylaxis
 Rifampin:
substantially
decreased

38
 omeprazole
concentrations
Pantoprazol Anti- For the treatment of Reduces gastric 40/30m  CNS: dizziness, headache  Ampicillin,  Assess for
e+Domperi Ulcerant gastroesophageal acid secretion g 1 tab  CV: chest pain cyanocobalamin, symptomatic
dine reflux disease; non- and increases once a  EENT: rhinitis digoxin, iron salts, improvement.
ulcer dyspepsia, gastric mucus day  GI: vomiting, ketoconazole:  Monitor blood
gastric or duodenal and bicarbonate diarrhea, abdominal pain, delayed absorption glucose level in
ulcer, dyspepsia, production, dyspepsia Metabolic: of these drugs diabetic patient.
bloating, fullness, creating hyperglycemia  Atazanavir,  Tell patient to
belching, NSAID protective  Musculoskeletal: hip, nelfinavir: swallow
induced dyspepsia. coating on wrist, spine fractures (with substantially delayedrelease
gastric mucosa long-term daily use) decreased tablets whole
 Skin: rash, pruritus atazanavir or without crushing,
 Other: injection site nelfinavir plasma chewing, or
reaction concentration with splitting.
loss of therapeutic
effect and
development of
drug resistance

Norplat Antiplatelet  Recent Inhibits 75mg 1 tab OD  CNS: depression, Abciximab, aspirin,  Monitor
myocardial platelet dizziness, fatigue, eptifibatide, hemoglobin
infarction aggregation headache heparin, and hematocrit
(MI) or by blocking  CV: chest pain, heparinoids, periodically.
stroke or binding of hypertension nonsteroidal anti-  Monitor
established adenosine EENT: epistaxis, inflammatory drugs patient for
peripheral diphosphate rhinitis (NSAIDs), unusual
arterial to platelets,  GI: diarrhea, thrombolytics, bleeding or
disease thereby abdominal pain, ticlopidine, bruising; drug
preventing dyspepsia, tirofiban, warfarin: significantly

39
thrombus gastritis, increased risk of increases risk
formation GI bleeding bleeding of bleeding.
 Hematologic: CYP2C19  Assess for
bleeding, inhibitors (such as occult GI
neutropenia, esomeprazole, blood loss if
thrombotic omeprazole): patient is
thrombocytopenic significantly receiving
purpura reduced clopidogrel naproxen
 Metabolic: antiplatelet activity concurrently
hypercholesterole Fluvastatin, many with
mia, gout NSAIDs, phenytoin, clopidogrel.
Musculoskeletal: tamoxifen,  Advise patient
joint pain, back tolbutamide, to immediately
pain Respiratory: torsemide: report unusual
cough, dyspnea, interference with or acute chest
bronchitis, upper metabolism of these pain,
respiratory tract drugs respiratory
infection, difficulty, rash,
bronchospasm purplish
Skin: pruritus, bruises on skin
rash, angioedema or in mouth,
purple skin
patches,
unusual
fatigue, fast
heart rate,
confusion,
signs and
symptoms of
stroke
(including

40
 weakness on
oneside,
speech
changes), low
urine output,
unresolved
bleeding,
diarrhea, GI
distress,
nosebleed, or
acute
headache.

2. EXERCISE/ACTIVITY and HOME ENIVRONMENT

1. Depending on the status, the patient is encouraged to return to usual activities gradually.
a) Encourage the patient and instructed the significant others to control activities for daily living
b) Encourage the patient and instructed the significant others to participate in passive active range of motion as tolerated
c) Instructed the significant others to provide safety precautions to the patient, especially when ambulating or using a bathroom
d) Instructed the significant others to include 30 minutes of walking as tolerated
a) Encourage patient to include atleats 30 minutes of walking
e) or jogging or perform tolerated and preferred activities as a means of exerci

RESTRICTIONS:

41
 1. Strenuous activities
2. Heavy lifting greater than 5kg
3. Prolonged exposure to sunlighrt

HOME ENVIRONMENTAL HAZARDS:

a) Restrict smoker
b) Crowded area

3. TREATMENTS/THERAPIES
a) Attending the follow up check up :
 Educate client by adhering maintenance therapy, appropriate diet and having exercise will reduce likelihood

of occurrence and aggravation of disease.

4. HEALTH TEACHING/EDUCATION
PREVENTION/PROMOTION
Health teaching about the disease, exercise and diet
 Instructs the patient about home-made interventions in reducing blood such as:
a.) Pineapple or calamansi juice to reduce blood pressure
b) chewing of raw or fried garlic after meals
c.) refrain from consumption of caffeinated beverages, such as coffee and chocolate

42
5. OPD Visit
Instruct that they need to have a health check up
 Emphasize the importance of adhering to medications and attending follow-up check.
 Encourage patient to adhere to weakly blood pressure monitoring.

6. DIET
 Low calories- calorie restriction in individuals with hypertension
 Low fat- Advisable to reduce the fat consumption since hypertension has greater risk of atherosclerotic. Foods rich in cholesterol are liver, meat organ, egg
yolk,lobster, crabs, and prawns. Recommended: vegetable oil like sunflower and olive oil
 High protein: Most high protein foods are extremely low in carbs and extremely low in saturated fat. Therefore, by eating a high protein diet loaded with high
protein foods, at the same time you’d end up eating low carbs and low saturated foods
 Low sodium and High in potassium: Help to lower blood pressure
Foods rich in potassium: tomato, watermelon, banana, apple, raw carrots, leafy vegetables and potato
r
7. SPIRITUAL CARE AND PSYCHOLOGICAL OR SEXUAL NEEDS
(/) Spiritual counseling
(/) Grief work
(/) Anger Management
(/) Confession
(/) Family therapy

43
(/) Reconciliation of conflicted Relationships
(/) Supportive Counseling
(/) Join church Organizations/Activities
(/) Prayer
(/) Meditation, Reflection, and Spiritual Devotion
(/) Religious rituals
(/) Religious/ Spiritual Materials

SEXUAL NEEDS
(/) Marriage counseling
(/) Sex Therapy
(/) Sexual Therapy
(/s) Referral to appropriate Agencies

44
References:

1. Taylor (2008) Nursing Diagnosis Pocket Guide (2th ed.).Philadelphia: Wolters

Kluwer Health/Lippincott Williams & Wilkins.

2. Lewis, Heitkemper ,Dirksen ,O'Brien,Bucher (2007): Assessment and

Management of Clinical Problems, liver, Pancreas and Biliary Tract problems,
Medical Surgical Nursing, MOSBY.1st Edition, 1101:15.

3. Ignatavicius & Workman (2006) Medical Surgical Nursing: Critical Thinking for
Collaborative Care. USA. Elsevier.

4. Smeltzer & Bare (2004). Medical- Surgical Nursing. Philadelphia. Lippincott

Williams & Wilkins.

5. Tortora (2011). Principles of Anatomy and Physiology , 14th Edition John Wiley
& Sons, 2008.

6. Weber & Kelley (2014). Health Assessment In Nursing. Philadelphia. Lippincott

Williams & Wilkins.

7. Goldman and Schafer (2016).Goldman-Cecil Medicine. 25th ed. Philadelphia,

PA: Elsevier Saunders.

8. Cecil, Goldman,Bennett (2000).Cecil Textbook of Medicine . 21st ed.

Philadelphia, PA: WB Saunders Company.

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46