Universal Colleges of Parañaque

College of Nursing

CEREBRO VASCULAR ACCIDENT

RIGHT HEMIPARESIS INTRACEREBRAL BLEED

A group case study in partial fulfillment of the requirements for the course
Related Learning Experiences
Ospital Ng Parañaque

Submitted By:
Rubin, Ralph Kim Y.
Salvador, Erene Kara R.

BSN IV
 TABLE OF CONTENTS

I: Introduction

II: Demographic Data

II.1: Information source

II.2: Chief Complaint

II.3: History of Present Illness

II.4: Past Medical History

II.5: Family History

III: Physical Health Assessment

IV: Gordon’s Functional Health Pattern

V: Anatomy and Physiology

VI: Pathophysiology

VII: Laboratory/ Diagnostic Examinations

VIII: Course in the Ward

IX: Drug Study

X: Problem List

XI: Nursing Care Plan

XII: Discharge Planning

 I. INTRODUCTION

CEREBRO VASCULAR ACCIDENT RIGHT HEMIPARESIS INTRA CEREBRAL BLEED

The BSN level IV students were given the opportunity to have a hospital exposure at Ospital
Ng Parañaque – Medical Ward; and on that day we found commendable case reasonable to be
presented for a case study.
This study would help us as student nurse to comprehend the disease mentioned and other important
factors and we can also educate the families of each and everyone. Because cerebrovascular accident
can be fatal or it can lead to long-term disability, but some people will make a full recovery.

The sudden death of some brain cells due to lack of oxygen when the blood flow to the brain
is impaired by blockage or rupture of an artery to the brain. A CVA is also referred to as a stroke.
The cause of stroke is that an artery to the brain may be blocked by a clot (thrombosis) which typically
occurs in a blood vessel that has previously been narrowed due to atherosclerosis (hardening of the
artery). When a blood clot or a piece of an atherosclerotic plaque, a cholesterol and calcium deposit
on the wall of the artery breaks loose, it can travel through the circulation and lodge in an artery of
the brain, plugging it up and stopping the flow of blood; this is referred to as an embolic stroke. A
blood clot can form in a chamber of the heart when the heart beats irregularly, as in atrial fibrillation;
such clots usually stay attached to the inner lining of the heart but they may break off, travel through
the blood stream, form a plug (embolus) in a brain artery and cause a stroke. A cerebral hemorrhage
(bleeding in the brain), as from an aneurysm or widening and weakening of a blood vessel in the
brain, also causes stroke.

The Diagnosis of stroke can be CT Scan or Computerized Tomography Scan reveals brain
lesions and Cerebral Angiography reveals site and extent of mal-occlusion, it can be invasive by
injecting of dye.

Early use of anticoagulants to minimize blood clotting has value in some patients. Treatment
of blood pressure that is too high or too low may be necessary. The blood sugar (glucose) in diabetics
is often quite high after a stroke; controlling the glucose level may minimize the size of a stroke.
Drugs that can dissolve blood clots may be useful in stroke treatment. Clot retrieving interventions
can now be performed in some stroke centers. Oxygen is given as needed.

II. DEMOGRAPHIC DATA

 Name: Patient D. D.
Age: 59 years old
Gender: Male
Birth date: December 29, 1959
Birth Place: Pangasinan
Civil Status: Married
Nationality: Filipino
Religion: Catholic
Educational Background: High School Graduate
Address: Kawayanan Area, Marcelo Village Parañaque City
Occupation: Foreman
Admission Diagnosis: Cerebrovascular Accident Right Hemiparesis Intracerebral Bleed
Date and Time admitted: March 8, 2019 at 9:54 am
Height: 5’6”
Weight: 72kg

•SOURCE OF INFORMATION

Patient's
Daughter
Chart
50%
50%

CHIEF COMPLAINT
“Hindi niya kasi magalaw yung kanang kamay niya ” as verbalized by his daughter.

HISTORY OF PRESENT ILLNESS:

-The patient experienced face and arm unable to move, the right side of the body appropriately one and
a half hour prior to admission.

PAST MEDICAL HISTORY

 A. Disease or Illness during Childhood:
-It was according to his daughter knows that the patient has not been hospitalized and doesn’t have any
major childhood disease except for coughs and common colds.

B. Known Allergies:
-His daughter stated that he has no known allergies.

C. Accidents and Injuries:

- The Daughter of patient D. D. stated that her father has not been involved in any accidents and
doesn’t have any injuries.

D. Previous Hospitalizations:
- The Daughter of patient D. D. stated that this is the second time he has going to hospital but the
first one was only checked in the Emergency room and advised to go home and the second one he is
now hospitalized.

E. Medications currently taken:

-Cefuroxime, Comvibent, Citicoline, Losartan and Omeprazole.

F. Chronic Health Condition:

- His daughter stated that he doesn’t have any serious condition except for High blood.

•FAMILY HISTORY:

Father:
Mother Hypertensive
(Confirmed)

Patient:
Hypertensive
(Confirmed)

III. PHYSICAL HEALTH ASSESSMENT

VITAL SIGNS AS OF 8:00 AM

(MARCH 10, 2019) (MARCH 11, 2019)

BLOOD PRESSURE: PULSE RATE: BLOOD PRESSURE: PULSE RATE:

140/80 95 bpm 130/80 93 bpm
RESPIRATORY RATE: TEMPERATURE: RESPIRATORY RATE: TEMPERATURE:
22 cpm 36.6 °C 20 cpm 36.3 °C

BODY PARTS ACTUAL FINDINGS NORMAL FINDINGS INTERPRETATION

Pinkish and Pinkish color and No presence of

uniform skin color uniform skin color abnormalities
with no lesions and no lesion No presence
Skin No sign of dryness No sign of dryness abnormalities
and no deep and no deep
cracking cracking
Slightly warm to warm to touch
touch Smooth and soft
Smooth and soft

Head and Head is Negative

symmetrical, symmetrical and abnormalities
Head centered centered Negative
Face is centered Face is centered abnormalities
position and face is position and face
symmetrical is symmetrical

Fine and thin hair Fine and thin hair Negative

Equal distribution Equal distribution abnormalities
Hair Black hair Black hair Negative
Fine and smooth Fine and smooth abnormalities
Negative
abnormalities
Negative
abnormalities

Eyes is centered Eyes is centered Negative

Eyes position position abnormalities

Eyebrows hair is Eyebrows is Negative

equally distributed equally distributed abnormalities
and the eyebrows is and the eyebrows Negative
centered is centered abnormalities
 Thin and its Thin and its
vocabulary blink voluntary blink
Pale color Pinkish color
Sclera is white and Sclera is white in
color and the color and palpebral
palpebral Clarity and smooth
Clarity and smooth
and regular contour

Nose Normal curvature Normal curvature Negative

With Nasogastric abnormalities
Tube For passage of
food and
medicines

Negative dryness Negative drying Negative

and pale color and and pinkish color abnormalities
no deep cracking and negative deep Negative
Pale color, no cracking abnormalities
Mouth lesions Pinkish color May indicate on
Missing teeth, 2 in negative lesions poor dental care
upper front and 2 in Complete set of
lower part teeth
(+) caries No caries, dentures
or braces

(-) lesions and (-) Negative lesions, Negative

Neck tenderness negative abnormalities
tenderness

Pinkish color Pinkish color Negative

Nails Shiny Shiny abnormalities
Curvature Curvature Negative
2 seconds abnormalities
Capillary Refill Negative
abnormalities
Negative
abnormalities

Non tender Non tenderness Negative

Abdomen No pain upon No pain upon abnormalities
palpation palpation Negative
abnormalities
 Glasgow Coma Scale

Date and Time taken:

Interpretation: Score of 8 interprets the patient is in comatose

NEUROLOGIC EXAM

Mental Status: Comatose

 Open Spontaneously 4
Eye Response Open to Verbal command 3
Open in Response to pain 2
No response 1
Talking/ Orientated 5
Confused speech/ 4
Verbal Response Disoriented
Inappropriate words 3
Incomprehensible sounds 2
No response 1
Obeys commands 6
Motor Response Localizes pain 5
Withdraws from pain 4
Abnormal flexion 3
Extension 2
No response 1
TOTAL 8
TIME PERRLA EXTREMITIES
LEFT RIGHT UPPER LOWER
R L R L
8am 3 3 2 5 2 5
10am 3 3 2 5 1 5
12nn 3 3 2 5 2 5
2pm 3 3 2 5 1 5
EXTREMITIES CODE
1- Twitch – No movement
2- Move against gravity
3- Lift against gravity
4- Move strong- Lift and Hold
5- Normal

(March 10, 2019) (March 11, 2019)

TIME VITAL SIGNS TIME VITAL SIGNS
BP PR RR TEMP O2 BP PR RR TEMP O2
8am 140/80 95 22 36.6°C 97% 8am 130/80 96 20 36.4°C 97%
10am 130/80 98 21 96% 10am 140/80 95 22 97%
12nn 140/80 94 23 37.2°C 96% 12nn 140/80 97 23 36.2°C 95%
2pm 130/80 97 21 95% 2pm 130/80 94 23 96%
 IV. GORDON’S FUNCTIONAL HEALTH PATTERN

Patterns and Questions Before Confinement During Confinement Identified Nursing

Diagnosis

I: Health Perception-
Health Management:

1. How is your health? • ”Malusog naman ang • “Di naman siya • Impaired verbal
papa ko di naman siya makapag salita gawa ng communication
sakitin” as verbalized by kondisyon niya” as
his daughter. verbalized by his
daughter.

2. What do you do when • ”Hindi naman kasi siya

you feel that something nag-sasabi tahimik lang
is wrong with your body? kasi si papa kaya hindi
namin alam kung may
nararamdaman na ba
siyang hindi maganda” as
verbalized by his
daughter.

3. Whenever you feel • “Hindi naman nga nag-

something wrong, what sasabi si papa” as
is your first action? verbalized by his
daughter.

4. Do you have any vices • “Oo naninigarilyo siya

like smoking or drinking nakaka isang pack siya
alcohol? How many ng sigarilyo, tuwing wala
packs of cigarettes he siyang pasok nag iinom
consumed in a day? siya pagka-gabi ng
sabado ayun nag iinom
na siya” as verbalized by
his daughter.

II: Nutrition-Metabolic:

1. How many times do • ”Umaga, tanghali at • “May nakalagay kasi sa • No Problem identified
you eat during the day? gabi” as verbalized by ilong niya eh kaya pag
his daughter. napunta lang yung nurse

2. What do you usually • “Ang hilig niya lang
eat at breakfast, lunch kainin gulay at mga isda
and dinner? ganun, hindi naman siya
mahilig sa mga karne
basta gulay at isda lang”
as verbalized by his
daughter.
• “Malakas siya uminom
3. Do you drink a lot of ng tubig eh, lagi siyang
water? How many glass a may dalang tubig pag
day? papasok sa trabaho” as
verbalized by his
daughter.
III: Elimination:
1. How many times do • “Syempre hindi ko
you pee and poop in a alam” as verbalized by
day? his daughter.
2. Thus your urine and • “Syempre hindi ko
stool normal? In color, alam” as verbalized by
consistency, odor, etc..? his daughter.
•“Syempre hindi ko
3. Is there a difficulty alam” as verbalized by
when you pee and poop? his daughter.
IV: Activity-Exercise:
1. Do you exercise? How • “ Yung trabaho niya pa
many times in a week? lang kasi exercise na” ”
as verbalized by his
daughter.
2. What are your other • “Wala kasi pagka-
leisure time and galing niya ng tarabaho
activities? nagpa-pahinga na agad
tsaka lang siya nakaka-
kain” as verbalized by
his daughter.
• Knowledge deficit
• “Di ko alam kung
anong pagkain na
binibigay ng nurse eh” as
verbalized by his
daughter.
•No Problem Identified
• “Pagka tapos niya lang
kumain dun lang yung
inom niya ng tubig” as
verbalized by his
daughter.
• “Simula nung na-admit
siya hindi pa siya
nakaka-dumi” as • Risk for Constipation
verbalized by his
daughter.
• Impaired urinary
• The patient has dark elimination
orange urine color as
seen in the patient’s urine
bag.
•Impaired physical
mobility
• The patient has no
activities due to his
present condition.
 siya sa bahay pero pag
wala siyang pasok nag
iinom siya” as verbalized
by his daughter.

V: Sleep-Rest:

1. Do you have good • “Sapat naman yung • “Tulog lang siya ng

sleeping habits? tulog niya kasi pagka- tulog” as verbalized by
galing niya ng trabaho ng his daughter. • No Problem Identified
mga alas-kwatro mga
2. How many hours do ala-syete ng gabi pag
you usually sleep at tapos naming kumain
night? papahinga lang siya tapos
matutulog na ” as
verbalized by his
daughter.

3. Do you take time to • “Nakakapag pahinga

relax during your free naman siya tuwing wala
time? siyang pasok” as
verbalized by his
daughter.

VI: Cognitive-
Perceptual:

1. Do you have problems

with your hearing or
eyesight?

2. How about your sense

of taste and smell? Do
you have any difficulty • “Wala naman siyang • “Ngayon ayun nga di • No Problem Identified
swallowing, smelling problema sa pandinig at siya nakaka-kain kaya
things or tasting? sa mata, maayos naman meron siyang ano sa
siya mag-salita, basta ilong” as verbalized by
wala naman siyang his daughter.
problema” as verbalized
3. Do you have difficulty by his daughter.
upon speaking? How
about difficulty thinking
and memory problem?

4. Do you have difficulty

making decisions?
VII: Role-Relationship:

1. How is your • “Okay naman kami sa • “Okay pa rin naman •No Problem Identified.
relationship with your bahay, di kasi kami kahit ganito yung
family? magagalitin si papa eh, sitwasyon ni papa” as
pag may problema siya verbalized by his
samin di naman siya daughter.
sumisigaw”
as verbalized by his
daughter.

2. How about your

relationship with other
people around you? Like • “Wala naman siyang
your boss, workmates, or nakukwento” as
friends? verbalized by his
daughter.

VIII: Self Perception-

Self Concept:
•Not applicable •Not applicable • No Problem Identified.
1. How do you feel about
yourself?

2. How do you feel?

3. How is your ability to

do some work or your
job?

IX: Sexuality-
Reproductive:
•Maayos naman ang pag • Not applicable •No Problem Identified.
1. Do have any special sasama nila ni mama
relationship? kahit nung bago mawala
 si mama” as verbalized
2. Do you have any by his daughter.
experienced on sex?
• Not applicable

X: Coping-Stress
Tolerance:
• “Yun nga tahimik lang • Not applicable •No Problem Identified.
1. How do you kasi siya di ma-kwento”
handle stress? as verbalized by his
What do you do daughter.
to manage or deal
with it?

XI: Values-Beliefs:

1. What is your religious • “Katoliko kami, pero di • Not applicable •No Problem Identified.
preference? And what are naman siya madasalin”
the different beliefs and as verbalized by his
traditions on your daughter.
religion?
 V. ANATOMY AND PHYSIOLOGY
(BRAIN AND HEART)

BRAIN

 The brain is composed of the cerebrum, cerebellum, and brainstem.

The brain has three main parts: the cerebrum, cerebellum and brainstem.

CEREBRUM
 Is the largest part of the brain and is composed of right and left hemispheres. It performs higher
functions like interpreting touch, vision and hearing, as well as speech, reasoning, emotions,
learning, and fine control of movement.
 The cerebrum is divided into two halves: the right and left hemispheres. They are joined by a
bundle of fibers called the corpus callosum that transmits messages from one side to the other.
Each hemisphere controls the opposite side of the body. If a stroke occurs on the right side of the
brain, your left arm or leg may be weak or paralyzed.
 CEREBELLUM
 Is located under the cerebrum. Its function is to coordinate muscle movements, maintain posture,
and balance.
BRAINSTEM
 Acts as a relay center connecting the cerebrum and cerebellum to the spinal cord. It performs
many automatic functions such as breathing, heart rate, body temperature, wake and sleep cycles,
digestion, sneezing, coughing, vomiting, and swallowing.

LOBES OF THE BRAIN

 The cerebral hemispheres have distinct fissures, which divide the brain into lobes. Each
hemisphere has 4 lobes: frontal, temporal, parietal, and occipital

BROCA’S AREA
 Lies in the left frontal lobe. If this area is damaged, one may have difficulty moving the tongue
or facial muscles to produce the sounds of speech. The person can still read and understand
spoken language but has difficulty in speaking and writing (i.e. forming letters and words,
doesn't write within lines) – called Broca's aphasia.
Wernicke's area:
 Lies in the left temporal lobe. Damage to this area causes Wernicke's aphasia. The individual
may speak in long sentences that have no meaning, add unnecessary words, and even create new
words. They can make speech sounds, however they have difficulty understanding speech and
are therefore unaware of their mistakes.

HEART

PERICARDIUM

 The heart sits within a fluid-filled cavity called the pericardial cavity. The walls and lining of the
pericardial cavity are a special membrane known as the pericardium. Pericardium is a type of
serous membrane that produces serous fluid to lubricate the heart and prevent friction between
the ever beating heart and its surrounding organs.

STRUCTURES OF THE HEART WALL

The heart wall is made of 3 layers: epicardium, myocardium and endocardium.

 Epicardium. Is a thin layer of serous membrane that helps to lubricate and protect the outside of the
heart. Below the epicardium is the second, thicker layer of the heart wall: the myocardium.
 Myocardium. Is the muscular middle layer of the heart wall that contains the cardiac muscle tissue.
Myocardium makes up the majority of the thickness and mass of the heart wall and is the part of the
heart responsible for pumping blood. Below the myocardium is the thin endocardium layer.
 Endocardium. I the simple squamous endothelium layer that lines the inside of the heart. The
endocardium is very smooth and is responsible for keeping blood from sticking to the inside of the heart
and forming potentially deadly blood clots.

The cardiac cycle includes all of the events that take place during one heartbeat. There are 3 phases to the
cardiac cycle: atrial systole, ventricular systole, and relaxation.

 Atrial systole: During the atrial systole phase of the cardiac cycle, the atria contract and push blood
into the ventricles. To facilitate this filling, the AV valves stay open and the semilunar valves stay
closed to keep arterial blood from re-entering the heart. The atria are much smaller than the ventricles,
 so they only fill about 25% of the ventricles during this phase. The ventricles remain in diastole during
this phase.
 Ventricular systole: During ventricular systole, the ventricles contract to push blood into the aorta
and pulmonary trunk. The pressure of the ventricles forces the semilunar valves to open and the AV
valves to close. This arrangement of valves allows for blood flow from the ventricles into the arteries.
The cardiac muscles of the atria repolarize and enter the state of diastole during this phase.
 Relaxation phase: During the relaxation phase, all 4 chambers of the heart are in diastole as blood
pours into the heart from the veins. The ventricles fill to about 75% capacity during this phase and will
be completely filled only after the atria enter systole. The cardiac muscle cells of the ventricles
repolarize during this phase to prepare for the next round of depolarization and contraction. During this
phase, the AV valves open to allow blood to flow freely into the ventricles while the semilunar valves
close to prevent the regurgitation of blood from the great arteries into the ventricles.

BLOOD FLOW TO THE HEART

Deoxygenated blood returning from the body first enters the heart from the superior and inferior vena
cava. The blood enters the right atrium and is pumped through the tricuspid valve into the right ventricle. From
the right ventricle, the blood is pumped through the pulmonary semilunar valve into the pulmonary trunk.

The pulmonary trunk carries blood to the lungs where it releases carbon dioxide and absorbs oxygen.
The blood in the lungs returns to the heart through the pulmonary veins. From the pulmonary veins, blood
enters the heart again in the left atrium.
 The left atrium contracts to pump blood through the bicuspid (mitral) valve into the left ventricle. The
left ventricle pumps blood through the aortic semilunar valve into the aorta. From the aorta, blood enters into
systemic circulation throughout the body tissues until it returns to the heart via the vena cava and the cycle
repeats.

MODIFIABLE NON-
FACTORS MODIFIABLE
VI. PATHOPHYSIOLOGY FACTORS
Lifestyle Age (55 and
Hypertension
above)
High salt and (BOOK BASED)
Gender
fat diet
(Male)
Hereditary

CEREBRAL ANEURYSM ARTERIOVENOUS

RUPTURE MALFORMATION

BLEEDING INTO THE BRAIN

TISSUE AND
SUBARACHNOID SPACE

BLOOD CLOTS IN
THE
SUBARACHNOID
SPACE
 BLOOD SUPPLY
INTERRUPTION

TISSUE
NECROSIS

NEURONAL DEATH

REGIONAL
PARALYSIS

TOTAL COMA DEATH

PARALYSIS

(CLIENT BASED)
MODIFIABLE NON-
FACTORS MODIFIABLE
Lifestyle FACTORS
(SMOKING, Age (59
ALCOHOL years old)
DRINKING) Gender
Hypertension (Male)

INCREASE BLOOD FLOW TO

THE BRAIN

WEAKENING THE WALLS OF BLOOD

VESSELS

RUPTURE OF ANTERIOR
CEREBRAL ARTERY
 INTRACEREBRAL HEMORRHAGE

HEMATOMA
FORMATION

INCREASE INTRACRANIAL
PRESSURE

DECREASE OXYGEN
SUPPLY

ALTERATION IN FRONTAL LOBE FUNCTION

COMATOSE AND
STUPOR BROCA’S APHASIA
HEMIPARESIS

VII. DIAGNOSTIC EXAMINATIONS

HEMATOLOGY

(March 8, 2019)

COMPONENTS NORMAL VALUES RESULT INTERPRETATION

7.9 NORMAL
WBC ADULT: 5-10
NEWBORN: 9-20

HEMOGLOBIN MALE: 140-170 18.5 (H) Elevated hemoglobin can also

FEMALE: 120-140 cause by dehydration and
smoking.

HEMATOCRIT MALE: 42-51vol% 56.8 (H) Elevated hematocrit may

FEMALE: 37-47vol% indicate polycythemia, some
caused include dehydration.

DIFFERENTIAL
COUNT:
 May indicate infection or
LYMPHOCYTTES ADULT: 25%-35% 24% caused by intense physical
exercise, severe stress or
malnutrition.

EOSINOPHILS 0.02-0.04 0.02 NORMAL

BASOPHILS 0.00-0.01 0.00 NORMAL

PLATELET 150-450 184 NORMAL

iCa 1.15-1.33 1.13(L) May result from a problem

with the parathyroid gland, as
well as from diet, kidney
disorders or certain drugs.

CHEMISTRY TEST

(March 9, 2019)

TEST NORMAL RANGE RESULT INTERPRETATION

FBS 3.9-6.4mmol/L 7.04(H) May indicate hyperglycemia.

UREA 2.8-7.2mmol/L 3.14 NORMAL

CREATININE 53-115umol/L 93.31 NORMAL

CHOLESTEROL 3.14-6.15mmol/L 3.24 NORMAL

TRIGLYCERIDE 0-2.18mmol/L 0.8 NORMAL

BLOOD URIC ACID 214-488 umol/L 279.54 NORMAL

HDL 0-4.4mmol/L 1.03 NORMAL

ALT 1-41U/L 15.88 NORMAL

AST 1-38u/L 20.98 NORMAL

LdL 0-3.36mmol/L 1.84 NORMAL

VLDL 0-2mmol 0.34

(March 9, 2019)

HbA1c 4.0-6.0% 4.6% NORMAL

CHEMICAL MICROSCOPY
ROUTINE URINALYSIS
(March 8, 2019)

MACROSCOPIC NORMAL VALUES RESULT INTERPRETATION

COLOR Pale to Dark yellow Yellow NORMAL

May occur occasionally due

TRANSPARENCY Clear Turbid to mild dehydration or renal
infection.

SPECIFIC GRAVITY 1.000-1.030 1.015 NORMAL

REACTION/ pH 5.0-7.0 6.0 NORMAL

CHEMICAL TEST
 GLUCOSE Negative Negative NORMAL

PROTEIN Negative +1 May indicate proteinuria

MICROSCOPIC

RBC 0-1/hpf Innumerable May indicate hematuria

PUS CELLS 0-2/hpf 3-6 NORMAL

BACTERIA Few/Present Few NORMAL

EPHITHELIAL CELLS Occasional NORMAL

PLAIN CRANIAL CT SCAN March 8, 2019

FINDINGS:

HISTRORY: Decreased Sensorium

Plain axial CT images of the head reveal the following:

There is an irregularly bordered focus of acute blood attenuation involving the left fronto-temporal
region measuring approximately 2.6 x 2 cm (WxAP), with an approximate volume of 52 ml. perimetric edema
is evident extending into the ipsilateral frontal lobe. The complex compresses on the left sylvian fissure and
indenting into the left insula and external capsule. The rest of the parenchymal density is normal with no focal
lesion evident. The gray-white matter interface is maintained.

The ventricles are normal in sized and configuration. The midline structures are undisplaced. The basal
cisterns are intact.

The sella turcica and pineal gland are not usual.

Segmental calcification of the vertebral, basilar and internal carotid arteries are appreciated.
 The included paranasal sinuses, petromastoids, orbits and bony calvaria are unremarkable.

IMPRESSION:

Intraparenchymal hemorrhage, left fronto-temporal region, with mild mass effects, as detailed above.

Atherosclerotic vessel disease

CHEST (AP) X-RAY March 8, 2019

FINDINGS:

Reticulonodular opacities are noted in the right upper lobe.

The Pulmonary vascular markings are normal.

The cardiac shadow is magnified.

The Diaphragm, lateral costophrenic sulci and bony thorax are unremarkable.

IMPRESSION:

PTB OF UNDETERMINED ACTIVITY, RIGHT UPPER LOBE.

MAGNIFIED HEART.

VIII. COURSE IN THE WARD

DATE AND DOCTOR’S ORDER NURSING RATIONALE OF NURSING

TIME INTERVENTION INTERVENTION

March 10, 2019  IVF PNSS 1L x  To maintain the normal

4:00 pm KVO  IVF regulated Blood pressure
and  IVF to promote
 Nicardipine Drip administered hydration
Nicardipine 20 mg medication as
in PNSS 80 ml in ordered
soluset as S.D.V x
1mg/ hour titrate
accordingly to
maintain SBP
120/140

March 11, 2019  Nicardipine drip to

12:30 am follow:  IVF regulated
 Nicardipine 20 mg and  To promote hydration
in PNSS 80 ml in administered  To prevent fluid overload
soluset to run at 1
 mg/ hr titrate medication as
accordingly to ordered
maintain
SBP120/140
mmHg (3 cycles)

11:00 pm  BP 120-140  To provide baseline data

 O2 Saturation >  Obtain vital sign
94% as ordered
 CBG 140-180
 Temperature < 38
C
 Transfer to ICU  For intensive care and
once evaluated  Transfer the treatment
patient as soon
as possible and
endorsed to the
doctors once
 Decrease IVF evaluated  To prevent fluid overload
PNSS 1L at 120  Regulated/
ml/ hour monitored the
IVF gtts/ min as
ordered
 Maintain fluid  To manage the fluid
balance at 500-800  Monitored input balance
ml/ day and output of
the patient
IX. DRUG STUDY

GENERIC/ BRAND INDICATION SIDE EFFECT NURSING

NAME CONIDERATION

CEFUROXIME Serious lower Phlebitis, Monitor patient

respiratory tract thrombophlebitis, for signs and
DOSAGE: infection, UTI, diarrhea and symptoms of
 Infusion: 750 mg, skin to skin nausea superinfection
1.5 g/ vials, structure and diarrhea
infusion packs infections, bone or
 Injection: 750 mg, joint infection, PATIENT
1.5 g septicemia, TEACHING
meningitis, and
gonorrhea. Tell patient to
take drug as
CONTRANDICATION prescribed, even
after he feels
Contraindicated in better.
patients If patient has
hypersensitive to difficulty
drug or other swallowing
cephalosporins tablets, show
 him how to
Use cautiously in dissolve or crush
patients with tablets, but warn
history of colitis him that the
or renal bitter taste is
insufficiency hard to mask,
even with food.

OMEPRAZOLE Frequent heart Abdominal pain, Long term

burn constipation, therapy may
DOSAGE: Duodenal ulcer diarrhea, cause vitamin
Capsule: 10 mg, To suppress gastric flatulence, b12 absorption
20 mg, 40 mg acid secretion nausea, and problems.
Powder: 2.5 vomiting.
Tablets: 20 mg CONTRAINDICATION PATIENT
TEACHING
Contraindicated in
patients in Tell the patient
hypersensitive to to swallow
drug or its tablets whole
components and not to open,
Use cautiously in crush or chew
patient them
hypokalemia and Instruct the
respiratory patient to take
alkalosis in drugs at least 1
patients on a low- hour before
sodium diet and in meals
breastfeeding
women.

LOSARTAN Hypertension, to Dizziness, Drug alone can

reduce risk of fatigue, headache, be used alone or
DOSAGE: stroke in patients insomnia, nasal with other anti-
Tablets: 25 mg, with hypertension congestion, hypertensive
50 mg, 100 mg and left sinusitis, sinus, drugs
ventricular disorder, cough Monitor
hypertrophy. and upper patient’s blood
respiratory tract pressure closely
CONTRAINDICATION infection. to evaluate
effectiveness of
Contraindicated in therapy.
patients in Monitor patients
hypersensitive to who are also
drug. taking diuretics
Use cautiously in for symptomatic
patients with hypotension.
impaired renal or
hepatic function.
 PATIENT
TEACHING

Tell patient to
avoid salt
substitutes; these
products contain
potassium,
which can cause
high potassium
level in patients
taking losartan.

GENERIC/ BRAND INDICATION SIDE EFFECT NURSING

NAME CONSIDERAION

MANNITOL Oliguria, to prevent Seizures, Monitor vital

oliguria or acute renal dizziness, signs, including
DOSAGE: failure, to reduce headache, fever, central venous
Injection: 5%, intraocular or edema, pressure, and
10%, 15%, intracranial pressure thrombophlebitis, fluid intake and
20%, 25% or cerebral edema hypotension, output hourly.
hypertension, Report
CONTRAINDICATION heart failure and increasing
tachycardia oliguria. Check
Contraindicated to in weight, renal
patients with anuria; function, fluid
severe pulmonary balance, and
congestion; frank serum and
pulmonary edema; urine sodium
active intracranial and potassium
bleeding (except levels daily.
during craniotomy); In comatose or
severe dehydration. incontinence
patients, use
urinary catheter
 because
therapy is
based on strict
evaluation of
fluid intake ad
output. If
patient has
urinary
catheter, use an
hourly
urometer
collection bag
to evaluate
output
accurately and
easily.

PATIENT
TEACHING

Tell patient that

he may feel
thirsty or have
a dry mouth,
and emphasize
importance of
drinking only
the amount of
fluids ordered.
Instruct patient
to promptly
report adverse
reactions and
discomfort at
I.V site.

COMBIVENT Management of Headache, Administer

reversible dizziness, nausea, accurately
DOSAGE: bronchospasm because
dry mouth,
Oral: 2 or 4 mg (1-2 associated with adverse
shaking
tsp syrup) three to obstructive airway reactions and
(tremors),
four times a day diseases in patients tolerance might
nervousness, or
ER tablets: 4-8 mg who require more than occur
cold symptoms
every 12 hours a single Raise side rails
such as stuffy
Inhalation: 1 or 2 bronchodilator up because
nose, sneezing,
inhalation/s every client might be
CONTRAINDICATION restless and
4-6 hours (1 aerosol cough, or sore drowsy because
dispenser: 90 mcg) Hypertrophic throat. of this drug
obstructive Assess pulse
cardiomyopathy or for rhythm
tachyarrhythmia Auscultate
lungs for
presence of
adventitious
breath sounds
that may signal
pulmonary
edema, airway
resistance or
bronchospasm

PATIENT
TEACHING

Advise patient
to seek
assistance in
performing
activities of
daily living
because the risk
of feeling weak
as well as
having vertigo,
drowsiness, and
headache is
possible
Advise client to
have small
frequent
feedings to
avoid
increasing risk
of vomiting and
heartburn

CITICOLINE Cerebrovascular Fleeting and Instruct patient

diseases – e.g. from discrete to take the
DOSAGE: ischaemia due to hypotension medication as
Oral: 200-600 stroke, where effect, Increased prescribed.
mg/day in Citicoline accelerates parasympathetic Teach the
divided doses the recovery of effects, patient that
IV/IM: The consciousness and Hypotension, citicoline may
recommended overcoming motor Itching or hives, be taken with
dose is up to 1 deficit. Swelling in face or without
g/day Head Trauma of or hands, Chest food.
varying severity: In a tightness, Monitor for
clinical trial, Tingling in adverse effects;
Citicoline accelerated mouth and throat, instruct patient
the recovery from Headache, to report
post-traumatic coma Nausea, immediately if
and the recuperation Diarrhea, Blurred he/she develops
of walking ability, Vision chest tightness,
achieved a better final tingling in
functional result and mouth and
reduced hospital stay. throat,
Cognitive disorders of headache,
diverse etiology – e.g. diarrhea and
senile cognitive blurring of
impairment which is vision.
secondary to
degenerative diseases
(e.g. Alzheimer’s
disease). Citicoline
improves scores on
cognitive evaluation
scales and slowed the
progression of
Alzheimer’s disease.
Parkinson’s disease –
Citicoline has also
been shown to be
effective as co-therapy
for Parkinson’s
disease. Beneficial
neuroendocrine,
neuroimmunodulatory,
and
neurophysiological
effects have been
described.

CONTRAINDICATION

Hypersensitivity
Patients with
hypertonic of the
parasympathetic.
 X. PROBLEM LIST

PROBLEM NUMBER PROBLEM DATE IDENTIFIED DATE RESOLVED

1 Altered breathing March 10, 2019 Indefinite Time
pattern

2 Impaired verbal March 10, 2019 Indefinite Time

communication

3 Knowledge deficit March 10, 2019 Indefinite Time

 4 Risk for constipation March 10, 2019 Indefinite Time

5 Impaired urinary March 10, 2019 Indefinite Time

elimination

6 Impaired physical March 10, 2019 Indefinite Time

mobility

XI. DISCHARGE PLANNING

MEDICATION
-Continue taking medication as prescribe on exact dosage, time & frequency and make sure that the
purpose of the medication is fully disclosed by health care provider.

ENVIRONMENT
 -Turn the patient side to side every 2 hours to prevent bed sores
-Have ROM exercises to enhance body function

TREATMENT
-Instruct the relative to monitor the cholesterol level of the patient
-Insist physical therapy for improving strength

HEALTH TEACHING
-Instruct the patient how to have a healthy lifestyle, right foods to eat and foods to avoid
-Instruct the relative how to prepare low sodium and low-fat diet
-Instruct the relative of patient to provide a safe environment

OUT-PATIENT
-Instruct the relative to follow-up checkup as physician’s order to monitor the condition of patient

DIET
-Advise the patient’s relative to eat nutritious foods such as vegetables and fruits
-Instruct the relative to avoid the foods that is high in cholesterol and salt on diet of patient

SPIRITUAL
-Encourage the patient to pray daily and ask for God’s continuous healing

XII. NURSING CARE PLAN

(ACTUAL)

ALTERED BREATHING PATTERN

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Altered After 8 hours Independent:
breathing of nursing  Auscultate  To evaluate After 8
Objective: pattern intervention. chest character of hours of
RR: 23 cpm The patient  Maintain breath sounds nursing
(+)Difficulty will establish calm  To limit level interventio
in breathing an effective attitude of anxiety n the
(+)Nasal breathing while  For better lung patient was
flaring pattern dealing expansion established
with patient an effective
 Position the breathing
patient in  To help the pattern as
semi patient in evidenced
fowlers breathing by the RR
position  For the with 20
Dependent: treatment of cpm and (-)
 Administer oxygen breathing difficulty
support as difficulties of
prescribed by breathing
doctor and (-)
 Administer nasal
bronchodilators as flaring.
prescribed by Goal met.
doctor
 IMPAIRED VERBAL COMMUNICATION RELATED TO PRESENT CONDITION

Nursing
Assessmen Diagnosis Planning Interventions Rationale Evaluation
t
Subjective Impaired After 8 hours
data: verbal of continuous Identify To assess and After 8
“Di naman communicatio nursing physiological delineate hours of
siya n related to interventions, or neurological underlying nursing
makapag present the patient will conditions conditions intervention
salita gawa condition participate in impacting affecting the patient
ng therapeutic speech such as verbal was able to
kondisyon communicatio severe communicatio communicat
niya” as n shortness of n e slowly.
verbalized breath, facial The goal
by his trauma, was partially
daughter”. neuromuscular met
weakness,
stroke or brain
trauma.

Plan for and

provide When the
alternative patient is able
methods of to write but
communication cannot speak
. Incorporating
information
about type of
disability
present:
provide pad
and pencil or
slate board

IMPAIRED URINARY ELIMINATION

Assessment Nursing Planning Interventions Rationale Evaluation

Diagnosis
Objective data:
Dark Impaired After 8 hours Provide latex- This reduces After 8 hours
colored urinary of Nursing free catheter the risk of of Nursing
urine elimination Intervention and care developing Intervention
400 ml the urine supplies sensitive to the urine
urine for output of latex, which output of the
the past patient will be can develop in patient was
24 hours increase from individuals increased from
400 ml to 700 requiring 400 ml to 600
ml frequent ml. The goal
catheterization was partially
or who have met.
long-term
indwelling
catheters.

To facilitate
drainage and
Demonstrate prevent reflux
proper
positioning of
catheter
drainage To reduce the
tubing and bag risk of
infection
Emphasize the
importance of
keeping the
area clean and
dry

IMPAIRED PHYSICAL MOBILITY RELATED TO PRESENT CONDITION

Assessment Nursing Planning Interventions Rationale Evaluation

Diagnosis
Objective data:
Impaired Impaired After 16 hours Provide or To maintain After 16 hours
ability to physical of Nursing assist with joint of Nursing
reposition mobility Intervention daily range mobility, Intervention the
self in bed related to the patient of motion improve patient shows
present will show (active and circulation signs of slightly
condition signs of passive) and prevent improvement in
improvement contractures. physical
in physical mobility. The
mobility goal was
Assist with To maximize partially met.
treatment of potential for
underlying mobility and
optimal
function

Change To improve
client’s circulation,
position reduce
frequently, tightening of
moving muscles and
individual joints,
parts of the normalize
body (arms, body tone,
legs, head) and more
using closely
appropriate simulate
support and body
proper boy positions an
alignment. individual
Encourage would
periodic normal use
changes in
head of bed,
with client in
supine and
prone
positions at
intervals

KNOWLEDGE DEFICIT DUE TO UNFAMILIARITY WITH INFORMATION RESOURCES

 Assessment Nursing Planning Interventions Rationale Evaluation
Diagnosis

Subjective: Knowledge After 8 hours Identify the Some After 8 hours

“Di ko alam deficit due to of Nursing learner: the patients of Nursing
kung anong unfamiliarity Intervention patient, family, especially Intervention
pagkain na with the relative significant older adults the relative
binibigay ng information will be other or the was able to
nurse eh” as resources familiarize in terminally ill fully
verbalized by the contents view understand the
his daughter. of NGT themselves as contents of
feeding dependent on NGT feeding.
the caregiver, The goal was
therefore will met.
not allow
themselves to
be part of the
educational
process.
Assess
motivation Learning
and requires
willingness energy.
of patient Patients must
to learn see a need or
purpose for
learning.
They also
have the right
to refuse
Consider educational
what is services
important
to the Allowing
patient the patient
to identify
the most
significant
content to
be
presented
first is the
Provide clear, most
thorough, and effective
understandable
explanations To clearly
and understand on
demonstrations. the side of the
patient or
relatives
 (POTENTIAL)

RISK FOR CONSTIPATION

Assessment Nursing Planning Interventions Rationale Evaluation

Diagnosis

Subjective: After 8 hours Auscultate Reflecting

“Simula nung Risk for of Nursing abdomen for bowel
na-admit siya constipation Intervention presence, activity
hindi pa siya the patient location, and
nakaka-dumi” will be able to characteristics
as verbalized defecate of bowel
by his sounds
daughter.
Promote It will help
adequate fluid good
intake, digestion
including
water, high
fiber fruits, and
vegetable
juices

Administer or To prevent
recommend constipation
medication
such as stool
softeners as
ordered
routinely,
when
appropriate