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Patients Profile
Chief complaint
> Washing clothes when sudden onset of slurred speech, blurred vision & right-sided facial weakness was experienced
Pathophysiology
Risk Factors:
Epithelium of blood vessel walls decreases elasticity with age Cell membrane alteration Possible chronic, undiagnosed and uncontrolled hypertension True/ apparent cardiomegaly
Prolonged vasocostriction
Inflammatory response
Further Vasoconstriction
Blurring of vision
Slurred speech Right sided facial weakness
Uncontrolled HPN
Rupture of blood vessels Change in LOC Basal Ganglia, Left, CVD Hemorrhagic Emergency craniectomy for evacuation of blood clot at left parietotemporal area
Difficulty swallowing
Impaired swallowing Risk for imbalanced nutrition Risk for aspiration Risk for aspiration
NGT insertion
Receptive aphasia Self-care Deficit Impaired physical mobility Activity intolerance Ineffective Role Performance Joint management of PT/OT Risk for possible urine retention
IFC insertion
Ensures accurate measurement of adequate urine output and efficacy of diuretic therapy
CT Scan (head)
Date Result 12/01/12 (+) basal ganglia hemorrhage, left. Approximately 46cc Acute left capsuleganglionic hemorrhage with secondary lateral ventricular compression and minimal subfalcine herniation 12/03/12 Almost complete resolution of acute capsuloganglionic hemorrhage; still with minimal mass effects Minimal pneumocephaly Implication/s Hemorrhagic stroke, left basal ganglia Intervention/s For emergency craniectomy evacuation of hematoma (left parietotemporal area) Nicardipine drip initiation Mannitol administration 150 cc stat Continuous monitoring of VS and NVS Mannitol 100cc q8 Furosemide 20 mg IV 3) min. post Mannitol
Successful craniectomy
CBG/ FBS
Reference Value 70110mg/dL
Date
Result
Implication/s
Intervention/s
12/01/12 119mg/ dL
Normal; done For FBS to determine comorbidity of DM and hypertension Above normal: OF: low fat, low could be an salt, diabetic effect of diet physiologic stress or possible DM
65-99mg/ dL
ABGs Analysis
Date
12/01/12
Result
pH: 7.276 PCO2: 39.1 HCO3:17.6
Implication/s
Metabolic acidosis: increased formation of acid in the body probably due to shifting to anaerobic metabolism (lactic acid build up)
Intervention/s
O2 inhalation @ 1 LPM/ NC
12/02/12
Respiratory alkalosis: may Anti-diuretic be due to the effect of admin cerebral edema on CNS that (mannitol, may cause stimulation to furosemide) the respiratory center Normal For repeat ABGs
12/03/12 AM
pH: 7.411 pCO2: 39.8 HCO3: 24.8 pH: 7.436 pCO2: 37.4 HCO3: 24.7
PM
Normal
12/05/12
WBC: 10.8
Hgb: 166
Hct: .511
12/10/12
WBC: 12.9
Serum ALT
Date 12/01/12 Result 26.4 U/L Reference Value F: 7-35U/L Implication/s Normal; was done to identify any damage to the liver which could be affected such as in the case of a fatty liver, hence may interfere drugs to be prescribed for the patient
Serum Creatinine
Date Result Reference Value Implication/s
12/01/12 77 umol/L
44-80
12/10/12 77 umol/L
Serum Sodium
Date Result Reference Value
136-145 mmol/L
Implication/s
Normal High; May indicate dehydration or may be due to the NGT feeding with inadequate fluid Normal
Interventions
Low salt, low fat OF preparation
12/10/12 142mmol/L
Serum Potassium
Reference Value 3.5-5.1 mmol/L
Date
Result
Interventions
12/12/12 3.50
Normal
Prolonged; No salicylates since there given was a WOF coffee bleeding, ground there were aspirates circulating products of fibrin and fibrinogen degradation in the blood, hence the increase.
9.8 -12.7 sec Normal Less than 2.0 for patients not receiving anticoagulatio n therapy
Urinalysis
Date 12/01/12 Result Implications
Reaction Metabolic alkalosis :alkaline Albumin:positive+ Probably benign proteinuria owing to physiologic stress Reaction :acidic Albumin:negative
12/05/12
Serum glucose
Date
Result
Lipid Profile
Date Result 12/02/12 HDL 1.15 Reference Value 0.91.56 mmol/L Implications WNL Interventions Low fat, low salt OF
LDL 4.61
2.59- 3.34 mmol/L High; May be due to diets high in cholesterol and fats;history of familial hyperlipoproteinemia; and obesity
Uric Acid
Date Result Reference Value 2.4- 5.7 mg/ dL Implications High; hyperuricemia: hypertension
12/02/12 10.8
Result
Bilateral pulmonary hypoinflation True or apparent mild cardiomegaly
Implications
Interventions
May be evident Turn side to of a restrictive side q2 lung disorder Maintenance due to obesity of O2 therapy
Review of Medications12/17/12
Zykast Carvedilol Losartan plus Cefixime Citicoline Simvastatin
Review of Systems
General Survey HEENT Cardiovascular Respiratory