Alas Dos Na Ya HAAH AA

A CASE PRESENTATION ON CEREBROVASCULAR

DISEASE

RLE GROUP 2 BSN 3A

OBJECTIVES

GeneralAfter this case study, we

will be able to know Many things about CVD including it’s causes, effects, signs and symptoms and how to manage patient that have experienced CVD.

SPECIFICKnowledge:• We will gain more information about the disease and the

disease process.• We will be able to know the considerations and

precautions of Patients with CVD.

Skills• We will be able to develop my skills in giving

appropriate nursing interventions based on the knowledge I have acquired.

• We will be able to know certain interventions that I have and don’t have to do.

• We will be able to enhance the way I give my interventions and give special considerations.

Attitude:• We will be able to know how to deal and communicate

with the patient.• We will be able to practice my intervention with

precautions to avoid inducing pain.• We will be able to give my care efficiently and with

empathy.

INTRODUCTION

Cerebrovascular disease (CVD) includes all disorders in which an area of the brain is transiently or permanently affected by ischemia or bleeding and one or more of the cerebral blood vessels are involved in the pathological process.

This results from sudden interruption of blood supply to the brain, which precipitates neurologic dysfunction lasting longer than 24 hours. Stroke are either ischemic, caused by partial or complete occlusions of a cerebral blood vessel by cerebral thrombosis or embolism or hemorrhage (leakage of blood from a vessel causes compression of brain tissue and spasm of adjacent vessels). Hemorrhage may occur outside the dura (extradural), beneath the dura mater (subdural), in the subarachnoid space (subarachnoid), or within the brain substance itself (intracerebral).

Risk factors for stroke include transient ischemic attacks (TIAs) – warning sign of impending stroke – hypertension, arteriosclerosis, heart disease, elevated cholesterol, diabetes mellitus, obesity, carotid stenosis, polycythemia, hormonal use, I.V., drug use, arrhythmias, and cigarette smoking. Complications of stroke include aspiration pneumonia, dysphagia, constractures, deep vein thrombosis, pulmonary embolism, depression and brain stem herniation.

Cerebrovascular accident/disease may be caused by any of three mechanisms.

Cerebral Thrombosis – blockage in the thrombus (clot) that has built up on the wall of the brain artery.

Cerebral Embolism – blockage by an embolus (usually a clot) swept into the artery in the brain.

Hemorrhage – Rupture of a blood vessel and bleeding within or over the surface of the brain.

Statistics (Incidence and Prevalence Rate)• CVD is the third leading cause of death after

heart disease and malignancy and it is estimated that an average of 500,000 new strokes will occur each year in the USA. CVD is the most disabling of all neurologic diseases. Approximately 50% of survivors have a residual neurologic deficit and greater than 25% require chronic care.

• The most common forms of cerebrovascular disease are cerebral thrombosis (40% of cases) and cerebral embolism (30%), followed by cerebral hemorrhage (20%).

ASSESSMENT

Patient’s DataNAME R.D.

AGE 65 YEARS OLD

SEX MALE

ADDRESS SWA. POB. PRES ROXAS CAPIZ

CIVIL STATUS MARRIED

RELIGION ROMAN CATHOLIC

NATIONALITY FILIPINO

OCCUPATION BAKERY OWNER AND BAKER

DATE AND TIME ADMITTED JULY 22, 2010 3:05 PM

WARD BLESSED ROSALIE RENDU WARD

CHIEF COMPLAINT LEFT SIDED WEAKNESS

ADMITTING DIAGNOSIS CVD SECONDARY TO INTRACEREBRAL HEMORRHAGE

PRE-OP DIAGNOSIS NONE

POST-OP DIAGNOSIS NONE

SURGICAL OPERATION PERFORMED NONE

FINAL DIAGNOSIS CVD SECONDARY TO INTRACEREBRAL HEMORRHAGE

SECONDARY BENIGN PROSTATIC HYPERPLASIA

ATTENDING PHYSICIAN DR. H.

History

History of Present Illness4 hours pta pt. had onset of dizziness after which

noted to have Left sided weakness, slurring of speech.He was brought to St. Anthony College Hospital and was admitted at Blessed Rosalie Rendu under the service of Dr. H.

Upon Admission:V/S: BP: 160/90 CR: 62 RR= 16Abdomen soft flabby, NT

Upon Admission:V/S: BP: 160/90 CR: 62 RR= 16

Abdomen soft feabby, NTGCS 13

(+) facial asymmetry Left(+) preferential Gaze Right

(+) nasolabial flattening Left (+) tongue deviation Left

(+) slurring of speech(+) babinski, poor gag reflex

B. Past HistoryPatient is hypertensive and is

taking amlodipine 10mg, 1tab- OD as maintenance and he is asthmatic.

Family HistoryFather: Mr. RA (deceased) gunshot Mother: Mrs. LA (deceased) hypertension

L.A(+)(+)HP

N

L.A(+)(+)HP

N

R.A. (+)gunshot

Asthmatic

R.A. (+)gunshot

Asthmatic

R.A(+)HPN

Asthmatic65

R.A(+)HPN

Asthmatic65

F.A(+)HPN

74

F.A(+)HPN

74

C.A.35

C.A.35

J.E(+)(+)HPN

J.E(+)(+)HPN

L.E. (+)(+)HPN

L.E. (+)(+)HPN

J.A.39

J.A.39

Patient

Deceased Male

Deceased Female

Female

Male

LEGEND:

Significant DataCategories Home Hospital

Sleeping Patterns: Usual Bedtime

Waking UpNo. of pillows

Problem regarding sleeping

Usual remedy

8:006:30

2NoneNone

7:006:00

2NoneNone

Categories Home HospitalElimination Pattern

Frequency:

Urination

Elimination

Problems

Usual Remedy

6 times a day

Once a day

None

None

6 times a day

3 times a week

None

Eating and Drinking Habits

Foods:

Preference

Dislikes

Fluids:

Preference

Dislikes

Hygiene practices:

Bath

Mouth care

Activities

Banana, Fruits, Fish and vegetables,pork

Egg, shrimp and hotdog

Water, soft drinks and coffee

Milo and juice

Once a day

3 times a day

Walking

Banana, fish, vegetables and fruits

SAME

Water

SAME

Twice a day half bath

Once a day

None

PHYSICALASSESSMENT

Cephalocaudal ApproachGeneral Appearance

He is lying on bed, conscious and coherent with no IVF attached. He had slurred speech. He can turn to right side only holding the side rails. He ate with assistance of the folks.

Body Part Findings interpretation

Face Symmetric with no involuntary movements, no presence of lesion, and no presence of tenderness.

NORMAL

Eyes Symmetrical to the ears, Right eye is cloudy in vision. Pupil is at the center and 2mm in size and brisk in reaction. Sclera is white in both eyes, eyelashes

are black and evenly distributed, eyebrows are

black and symmetric.

Glaucoma

Ears Symmetrical to the eyes, 10 degrees is the attachment, no

presence of discharges or secretions, no presence of

lesion, no presence of tenderness, ear canal is

smooth and pinkish in color

NORMAL

Nose Nose is at the midline, no presence of lesion, no

presence of discharges, mucosa is pink, nasal

septum is in the midline, no presence of tenderness, no

presence of nasal flaring.

NORMAL

Mouth Lips are assymetric, pink in color and moist, uvula is in the center, tongue is in the

center, pink in color, no presence of lesion, have a

smooth posterior and anterior surface, no

inflamed tonsils and pink in color, no presence of

tenderness.

Due to stroke attack

Neck No inflamed lymph nodes, no presence of

tenderness, no lumps and goiter noted, no palpable lymph nodes, no presence of lesion, symmetrical in

both sides, trachea in midline, no presence of

tenderness.

NORMAL

Chest Chest expands bilaterally, there is a presence of

moal( white in color), no presence of wheezing

sound upon auscultation, no presence of lesion, no

presence of tenderness, no presence of mass.

NORMAL

Breast No presence of lesion, no palpable lymph nodes,

symmetrical in sides, no presence of tenderness,

smooth to touch and areola is brown in color.

NORMAL

Cardiovascular System No presence of murmur sound upon auscultation, cardiac rate is 79 bpm, no

presence of lesions, no presence of tenderness,

and no presence of mass.

NORMAL

Abdomen No presence of lesions, no presence of tenderness,

smooth to touch, uniformly pinkish in color.

NORMAL

Axilla No palpable lymph nodes, no presence of lesion, no presence of tenderness,

smooth to touch, with hair.NORMAL

Upper extremities Left arm is pale and cold to touch, right arm is warm to

touch, no presence of lesions, no presence of

tenderness, both are equal in length.

Poor circulation on the left side of the body

Genito- Urinary System No presence of lesion, no presence of tenderness, no presence of redness. NORMAL

Ankles and feet Left feet is pale and cold to touch, no presence of

swelling, no presence of redness, no presence of

deformities.

Poor circulation on the left side of the body

Lower extremities Left feet is pale and cold to touch, no presence of

lesions, no presence of tenderness, right feet is warm to touch, both are

smooth to touch.

Poor circulation on the left

side of the body

TEXTBOOKDISCUSSION

Cerebrovascular Disorders is an umbrella term that refers to a functional abnormality of the central nervous system that occurs when the normal blood supply to the brain is disrupted.

Cerebrovascular disease (CVD) includes all disorders in which an area of the brain is transiently or permanently affected by ischemia or bleeding and one or more of the cerebral blood vessels are involved in the pathological process.

ANATOMY AND PHYSIOLOGYANATOMY AND PHYSIOLOGY OF THE NERVOUS

SYSTEM

The nervous system is the major controlling, regulatory, and communicating system in the body. It is the center of all mental activity including thought, learning, and memory. Together with the endocrine system, the nervous system is responsible for regulating and maintaining homeostasis.

Organization of the Nervous SystemAlthough terminology seems to indicate otherwise,

there is really only one nervous system in the body. Although each subdivision of the system is

also called a "nervous system," all of these smaller systems belong to the single, highly

integrated nervous system. Each subdivision has structural and functional characteristics that distinguish it from the others. The nervous

system as a whole is divided into two subdivisions: the central nervous system (CNS)

and the peripheral nervous system (PNS).

The Central Nervous SystemThe brain and spinal cord are the organs of the

central nervous system. Because they are so vitally important, the brain and spinal cord,

located in the dorsal body cavity, are encased in bone for protection. The brain is in the cranial vault, and the spinal cord is in the vertebral canal of the vertebral column. Although considered to be two separate

organs, the brain and spinal cord are continuous at the foramen magnum.

Central Nervous System Spinal Cord

The spinal cord is a long bundle of neural tissue continuous with the brain that

occupies the interior canal of the spinal column and functions as the primary

communication link between the brain and the rest of the body. The spinal cord receives signals from the peripheral senses and relays

them to the brain.

Brain Stem The brain stem is the part of the brain that connects the

cerebrum and diencephalons with the spinal cord. Medulla Oblongata

The medulla oblongata is located just above the spinal cord. This part of the brain is responsible for several vital autonomic

centers including: The respiratory center, which regulates breathing. The cardiac center that regulates the rate and force of the

heartbeat. The vasomotor center, which regulates the contraction of smooth

muscle in the blood vessel, thus controlling blood pressure.The medulla also controls other reflex actions including vomiting,

sneezing, coughing and swallowing.

PonsThe pons lie just above the medulla and acts as a link between various parts of the brain. The pons connect the two halves of the cerebellum with the brainstem, as well as the cerebrum with the spinal cord. The pons, like the medulla oblongata, contains certain reflex actions, such as some of the respiratory responses.

Midbrain The midbrain extends from the pons to the diecephalon. The midbrain acts as a relay center for certain head and eye reflexes in response to visual stimuli. The midbrain is also a major relay center for auditory information.

Diencephalon The diencephalon is located between the cerebrum and the mid brain. The diencephalons houses important structures including the thalamus, the hypothalamus and the pineal gland.

Thalamus The thalamus is responsible for "sorting out" sensory impulses and directing them to a particular area of the brain. Nearly all sensory impulses travel through the thalamus.

Hypothalamus The hypothalamus is the great controller of body regulation and plays an important role in the connection between mind and body, where it serves as the primary link between the nervous and endocrine systems. The hypothalamus produces hormones that regulate the secretion of specific hormones from the pituitary. The hypothalamus also maintains water balance, appetite, sexual behavior, and some emotions, including fear, pleasure and pain.

Cerebellum The functions of the cerebellum include the coordination of voluntary muscles, the maintenance of balance when standing, walking and sitting, and the maintenance of muscle tone ensuring that the body can adapt to changes in position quickly.

CerebrumThe largest and most prominent part of the brain, the cerebrum governs higher mental processes including intellect, reason, memory and language skills. The cerebrum can be divided into 3 major functions:

• Sensory Functions - the cerebrum receives information from a sense organ; i.e., eyes, ears, taste, smell, feelings, and translates this information into a form that can be understood.

• Motor Functions - all voluntary movement and some involuntary movement.

• Intellectual Functions - responsible for learning, memory and recall.

Meninges The meninges are made up of three layers of connective tissue that surround and protect both the brain and spinal cord. The layers include the dura mater, the arachnoid and the pia matter.

Cerebrospinal Fluid The cerebrospinal fluid is a clear liquid that circulates in and around the brain and spinal cord. Its function is to cushion the brain and spinal cord, carry nutrients to the cells and remove waste products from these tissues.

CAUSES• Cerebrovascular accident may be caused by any

of three mechanisms.• Cerebral Thrombosis – blockage in the

thrombus (clot) that has built up on the wall of the brain artery.

• Cerebral Embolism – blockage by an embolus (usually a clot) swept into the artery in the brain.

• Hemorrhage – Rupture of a blood vessel and bleeding within or over the surface of the brain.

CLASSIFICATION– Ischemic Stroke-caused by thrombosis or

embolism that obstructs the blood flow.– Hemorrhagic Stroke- caused by bleeding into the

brain tissue, the ventricles and subarachnoid space.

Item Ischemic Hemorrhagic

Causes Large artery thrombosisSmall penetrating thrombosis

Cardiogenic embolic

Intracerebral hemorrhageSubarachnoid Hemorrhage

Cerebral Aneurism

Main presenting symptom Numbness or weakness of the face, arm,or leg, esp. on one side of the body

Exploding headache

Functional Recovery Usually plateaus at 6 mos. Slower, usually plateaus at about 18 mos.

RISK FACTORS1. Hypertension-most important risk factor for

all stroke types; no defined BP indicating increased stroke risk, but risk increases proportionately as BP increases.

2. Heart DiseasesCHFCADRheumatic Heart Disease

3. TIAs, prior stroke, carotid bruits4. Increased hematocrit, increased fibrinogen5. Sickle Cell Disease6. Lifestyle Factors

Age (older)Alcohol abuseCigarette smokingDrug abuseGenetic factorsMales

7. Diabetes Mellitus8. Migraine HA’s9. Retinal emboli

SIGNS AND SYMPTOMS• Blurring or decreased vision in one or both eyes • severe headache, often described as "the worst

headache of my life" • weakness, numbness, or paralysis of the face,

arm, or leg, usually confined to one side of the body

• dizziness, loss of balance or coordination, especially when combined with other symptoms

• Difficulty of swallowing

COMPLICATIONSIschemic Stroke– Tissue Ischemia– Aspiration Pneumonia– Urinary tract infections– Cardiac Dysrhythmias– Complications of immobility

Hemorrhagic Stroke• Rebleeding or hematoma expansion• Cerebral Vasospasm• Cerebral Ischemia• Acute Hydrocephalus• Seizures

Vasoconstriction

Blockage of the Blood VesselEmbolism

Lack of Oxygen and nutrients supply

Hypoxia

Decreased Cerebral perfusion

Local acidosis

Cytotoxic Edema

Aneurysm Rupture

Brain Tissue Necrosis

Altered cerebral metabolism

Cerebral Ischemia

Cell death decreased Oxygen level

Intra cerebral hemorrhage

PARALYSIS

Ischemic Stroke

Subarachnoid Hemorrhage

Venous Stroke

Large Artery Strokes

Transient Ischemic Stroke

Small Artery Stroke

Embolic StrokesDEATHDEATH

Predisposing Factors:Lifestyle

AgeDiet

Precipitating Factors:Hypertension

HyperlipidemiaHeart diseasesAtherosclerosis

Thrombosis

MEDICALMANAGEMENT

PHARMACOLOGIC THERAPYIschemic Stroke

Recombinant Tissure Plasminogen Activator (r-tPA) Protocol--(For Select Patients Only)

1. Efficacy is influenced by the length of time between the onset of the stroke and the initiation of treatment

2. Rapid diagnosis and immediate administration of tPA increases its efficacy and may limit the potential for hemorrhagic conversion of ischemic stroke

• 3. Inclusion Criteria: ischemic stroke within 3 hours SBP < 185; DBP < 110• 4. Exclusion Criteria: isolated neurological deficit another stroke or serious head injury

within the previous 3 months INR > 1.7 use of heparin in the prior 48 hours major surgery in the prior 14 days platelet count < 100,000/mm3

5. tPA dose: 0.9 mg/kg body weight; max. dose 90

mg give 10% of the dose as a bolus over 1-

2 minutes and the rest as a continuous I nfusion over 1 hour

No antiplatelets or anticoagulants within 24 hours!!

6. Results: improved outcome with regard to disability and

death that persists 3 months after therapy there is a higher incidence of intracerebral hemorrhage (6.4% vs. 0.6%)

Intra-arterial Thrombolysis1. Early clot lysis and recanalization in about 50% of the

patients with intra-arterial streptokinase and urokinase

2. Intra-arterial r-pro UK 6 mg given within 6 hours of the stroke resulted in a 58% recanalization rate vs. 14% with placebo

3. Main concern is hemorrhagic transformation of the ischemic lesion

4. Risk of bleeding may increase with concomitant heparin

5. Should still be considered investigational until further data collected

Heparin1. useful for progressing stroke; questionable

role in stable or improving stroke2. Dosing: 50-70 U/kg as a loading dose, followed

by 10-25 U/kg/hour; goal PTT 1.5-2.0X control3. May opt to not use a loading dose in these

patients4. major concerns are conversion of an ischemic

stroke into a hemorrhagic stroke secondary to heparin, bleeding and thrombocytopenia

5. Careful selection of patients is important

Low-Molecular Weight Heparin (LMWH)1. Org 10172 has been studied in acute stroke

patients2. Synthetic low-molecular-weight fraction of

heparin3. Undergoing investigation in several clinical

trials4. Cannot be recommended for treatment until

the results of an ongoing multicenter study are reported

Ancrod (ARVIN)1. Derived from the venom of the Malayan pit viper snake2. Enzyme that breaks down fibrinogen to a soluble

ancrod-fibrin complex without allowing stabilization of fibrin (fibrin is not cross-linked)

3. May stimulate tPA activation from vascular endothelium4. Causes fibrinolysis soon after administration; low risk of

hemorrhagic complications5. Dose: 0.5 U/kg in NS over 6 hours; administered for 7

days following stroke in the clinical trials; titrate to a fibrinogen level of 0.5-1.0 g/L

6. Cannot recommend for use until further clinical trials are completed; role in therapy not yet established

Investigational Therapies for Acute Ischemic Stroke

Dextran Infusion1. Decreased blood viscosity by volume

expansion2. Decreased platelet function3. Decreased blood interaction with

endothelium

Prostacyclin

1. Potent vasodilator and platelet suppressant

2. Has fibrinolytic activity

Calcium Channel Blockers1. May increase CBF by smooth muscle relaxation2. May preserve neuronal function by preventing

the calcium influx into neurons that occurs during ischemia

3. nimodipine 30 mg PO every 6 hours for 28 days used in clinical trials; nicardipine also evaluated

4. Role in therapy not fully known at this time; seems to work best if initiated within 6-8 hours of symptom onset

Hemodilution

1. Utilize albumin and fluids to decrease hematocrit to 30- 35% which decreases blood viscosity

2. Questionable role in therapy

21-Aminosteroids (Tirilazad Mesylate-FREEDOX)1. During ischemia, free radicals are formed which

initiate lipid peroxidation2. 21-aminosteroids are potent inhibitors of lipid

peroxidation3. Doses up to 6.0 mg/kg/day divided into 4 doses IV x 5

days have been shown to be beneficial in clinical trials4. Role in therapy not yet defined; studies still ongoing

Hemorrhagic Stroke Calcium Channel Blockers (Nimodipine and Nicardipine)Anticonvulsants

DX:CEROVASCULAR

DISEASE

Symptoms:Blurring or decreased vision in one or both eyes severe headache, often described as "the worst headache of my life" weakness, numbness, or paralysis of the face, arm, or leg, usually confined to one side of the body dizziness, loss of balance or coordination, especially when combined with other symptoms Difficulty of swallowing

Nursing management:Monitored vital signs.Monitored neuro vital signs.Positioning every 2 hours.Monitored intake and output.

Prevention Quitting smoking Regular physical exerciseEating healthy diet of low fat contentMaintaining height, weight or voiding obesityControlling hypertensionAvoiding anger or chronic stressLowering blood cholesterol

Medical Management:Pharmacologic Therapy

Telmisartan ( MIcardis plus) 40g 1tab ODTrimetazidine (Vestar) 35G 1tab BIDMoxifloxacine (Avelox) 400g 1tab ODx 1 weekAllopurinol (Allerase) 300g 1tab ODAmlodipine (Norvasc) 5g 1tab ODZynapse 2.5 ml BIDHytrin 2 mg ½ tab @ HSCatapres/Atepras 5 mg 1tab OD

Possible ComplicationsBleeding or hematoma expansionCerebral vasospasm resulting in cerebral ischemia

Definition:A functional abnormality of the central nervous system that occurs when the normal blood supply to the brain is disrupted.

Diagnostic Test CT Scan or MRI to determine the type of strokeCerebral Angiography Fluid SerumUrinalysisHematologyStool ExamChest AP

Diagnostic examination

DIAGNOSTIC EXAMINATIONA. Fluid Serum July 23, 2010

Test Result Normal range significance

Glucose 6.42mmol/L 4.10-5.90 Hyperglycemia

Direct HDLC 2.05mmol/L 1.00-1.60 High Cholesterol

July 24, 2010

Test Result Normal range Significance

Potassium 135.4 umol/L 137-145umol/L Hypokalemia

Sodium 2.99umol/L 3.5-5.1umol/L Hyponatremia

Creatinine 199.2umol/L 71.0-133.0 Kidney Damage

July 26, 2010

Test Result Normal range Significance

Creatinine 177.4 umol/L 71.0-133.0 Kidney Damage

TPSA Determination (minividas)

0.86mg/ml 0-3.21mg/ml WNL

B. Urinalysis July 24, 2010Test Result Normal range Significance

microcospic

Color Pale straw Straw color to dark yellow

WNL

Transparency Slightly hazy Clear Presence of WBC

Reaction pH 5.0 4.5 – 8.0 WNL

Specific gravity 1.005 1.005 – 1.035 WNL

Red blood count 0-1 WNL

White blood count 0-2 WNL

Macroscopic

Amorph Occasional Occasional Normal

Epith Occasional Occasional Normal

• C.Hematology July 24,2010Test Results Normal range Significance

Hematocrit 0.37 g/L Male:0.40-0.54 Blood loss, anemia

Female:0.37-0.47

Hemoglobin 123 g/L Male: 135-180 Blood loss, anemia

Female:120-160

RBC 4.32 g/L Male: 4.6- 6.2 Erythrocytopenia

Female: 4.1-5.1

WBC 12g/L 4.5-11.0 Leukocytosis

Segmenters 0.78 50-65% Granulocytosis

Eosinophils 0.03 0-3% WNL

Lymphocytes 0.16 20-45% Lymphocytopenia

Platelet Adequate

D. Stool Exam: July 24,2010• Color: Brown• Consistency: Loose• Occult blood-(+)

E. CT Scan July 22,2010 Result: Atheromatous and tortuous aorta

cardiomegaly, LV form Dextroscoliosis, throracic spineF. Radiology: July 22, 2010Request: Chest APImpression: Artheromatous and Tortuous aortaCardiomegaly, Lv form Dextroscoliosis, Throracic

spine

PreventionDamage from stroke may be significantly

reduced through emergency treatment. Knowing the symptoms of stroke is as important as knowing those of a heart attack. Patients with stroke symptoms should seek emergency treatment without delay, which may mean dialing 911 rather than their family physician.

The risk of stroke can be reduced through lifestyle changes:

• quitting smoking • controlling blood pressure • getting regular exercise • keeping body weight down • avoiding excessive alcohol consumption • Getting regular checkups and following the

doctor's advice regarding diet and medicines, particularly hormone replacement therapy.

NURSING MANAGEMENT

Generic Name (Brand Name) and

DosageClassification Therapeutic Action Indications Adverse Effects Contraindications

Nursing Responsibilities

Amlodipine (Norvasc) 5 g 1 tab OD

AntihypertnsiveCalciumChannelBlockers

Inhibits the movement of calcium ions across the membranes of cardiac and arterial muscle cells; inhibits transmemebrane calcium flow which results in the depression of impulse formation in specialized cardiac pacemaker cells.

Essential hypertension, alone or in combination with other antihypertensive.

Headache, dizziness, fatigue,bradycardia, hypotension, palpitations andnausea

Contraindicated to allergy to amlodipine, impaired hepatic or renal function, heart failure and lactation.

Administer drug without regards to meals.

Administer with meals if upset stomach occurs.

Monitor VS very carefully if patient is in nitrates.

Generic Name (Brand Name) and

DosageClassification Therapeutic Action Indications Adverse Effects Contraindications Nursing

Responsibilities

Clonidine(Catapres)

5 mg 1 tab OD

Antihypertensive

Central Analgesic

Stimulate CNS alpha2-adrenergic receptors, inhibits sympathetic cardio accelerator and vasoconstrictor centers and decreases sympathetic outflow from the CNS.Prevents pain signal transmission to the CNS.

Hypertension, use alone or as a part of combination therapy

Drowsiness, headache, fatigue, sedation, dizziness, ,nausea and vomiting, rash, alopecia, bradycardia, tachydardia, dry mouth, urinary retention,

Contraindicated with allergy to clonidine.

Monitor BP carefully when discontinuing clonidine.

Advise patient to report any untoward reactions.

Generic Name (Brand Name) and Dosage Classification Therapeutic Action Indications Adverse Effects Contraindications Nursing

Responsibilities

Telmisartan +HCT

2(Micardis Plus) 40 g 1

tab OD

Antihypertensive

Angiotensine 2 recptor antagonist

Selectively blocks the binding of angiotensine 2 to specific tissue receptor: blocks the vasoconstriction effect of the rennin-angiotensine system leading to decrease BP.

Treatment of hypertension, in combination with other antihypertensive.

Dizziness, headache, nausea, vomiting, diarrhea

Contraindicated with allergy to telmisartan, pregnanacy and lactation.

Monitor patients BP carefully.Administer drug without regards to meals.Report any untoward reactions.

Generic Name (Brand Name) and

DosageClassification Therapeutic Action Indications Adverse Effects Contraindications Nursing

Responsibilities

Terazosine HCl(Hytrin)2 mg ½ tab

@ HS

AntihypertensiveAlpha1 Adrenergic Blocker

Selectively blocks postsynaptic alpha1 adrenergic receptor dilating arteriols and lowering BP.

TreatmentOfsymptomatcBPH.Treatmentofhypertensio

n.

Dizziness, weakness, GI upset, impotence, dry mouth

Contraindicated with allergy to terazosine and lactation.

Monitor patient for orthostatic hypertension

Monitor Vital signs.

Advise pt. to take this drug exactly as prescribed

Advise pt. to report any untoward reactions.

Generic Name (Brand Name)

and Dosage

Classification Therapeutic Action

Indications Adverse Effects Contraindications

Nursing Responsibilities

Citicoline(Zynapse) 2.5

ml BID

PeripheralVasodilatoCerebralActivators

Allergic reaction, itching, nausea, vomiting, dizziness

Contraindicated with allergy to citicoline, pregnancy and lactation.

Monitor Vital Signs especially the BP.

Report any untoward reactions.

Take with or without meals.

it activates the biosynthesis of structural phospholipids in the neuronal membrane, increases cerebral metabolism and increases the level of various neurotransmitters, including acetylcholine and dopamine. It shows neuroprotective effects in situations of hypoxia and ischemia.

CVD, in acute recovery phase

Generic Name (Brand Name) and

DosageClassification Therapeutic Action Indications Adverse Effects Contraindications Nursing

Responsibilities

Moxifloxacin (Avelox) 400 g 1

tab OD

Antibiotic (Fluroquinolone)

Bactericidal: Inhibits DNA synthesis in susceptible bacteria preventing cell reproduction causing cell death.

Treatment of adults with Community-Acquired Pneumonia.Treatment of complicated skin structure and skin infection.

Nausea, vomiting, abdominal pain, diarrhea, drowsiness, dizziness.

Contraindicated with allergy to fluroquinolones, hepatic and renal impairment , lactation and pregnancy.

Administer oral drugs before 4 hours or at least 8 hours after antacids.

Take oral drug once a day or as prescribed.

Advise patient to report any untoward reactions.

Generic Name (Brand Name) and

DosageClassification Therapeutic Action Indications Adverse Effects Contraindications Nursing

Responsibilities

Allopurinol(Allurase) 300 g 1 tab

OD

Antigout Inhibits enzyme responsible for the conversion of purines to uric acid, thus reducing the production of uric acid with a decrease in serum and sometimes in urinary uric acid levels, relieving the signs and symptoms of gout.

Management of the signs and symptoms of gout.

Management to patients with elevated serum and urinary uric acid.

Nausea, vomiting, loss of appetite after meals, drowsiness

Contraindicated with allergy to allopurinul, lactation and preganancy.

Administer this drug after meals.

Report rash, fever, chills, numbness or tingling and flank pain.

• Nursing Problem #1Nursing Diagnosis: Impaired physical mobility

related to neurologic impairment.Goal: To demonstrate techniques and behaviors

that enable resumption of activities.Outcome: To participate in ROM and ADL

exercises and to maintain skin integrity within the shift.

INTERVENTIONS EVALUATION

1. Assisted in repositioning every 2 hrs. No Break in the skin integrity noted at the end of the shift

2. Side rails used during position changes Able to use side rails as supportive device during position changes.No accidents or injuries occurred during position changes

3. Affected body parts supported for comfort. Able to rest comfortably in bed

4. Encouraged to participate in self care, diversional/recreational activities

Participated in some self care activities such as wiping his own face and neck.

5. Encouraged to participate in ROM exercises Participated in ROM exercises.

6. Provide rest periods Able to rest and relax after following exercises.

• Nursing Problem # 2Nursing Diagnosis: Self Care

Deficit related to neuromuscular impairment.

Goal: Demonstrate techniques/lifestyle changes to meet self care needs within the shift.

Outcome: To participate in selected self-care activities within the shift.

INTERVENTIONS EVALUATION

1. Encouraged to do simple self-care activities for himself.

Able to do such simple ways to clean himself such as wiping and cleaning his face and neck.

2. Taught techniques on how to wash or clean the body properly.

Able to wash and wipe certain parts of his body properly.

3. Assisted in caring for himself. Able to practice self-care in simple ways.

• Nursing Problem # 3Nursing Diagnosis: Impaired

verbal communication r/t neurologic impairment.

Goal: To establish method of communication in which needs can be expressed

Outcome: Pt. will be able to communicate his needs and feelings both verbally and non-verbally within the shift.

INTERVENTIONS EVALUATION

1. Encouraged pt. to express his self by means of sign language if not understood verbally..

Able to do express himself through making signs.

2. Encouraged family to talk to the pt. a lot.

Able to communicate with others and the family members more effectively

• Nursing Problem # 4Nursing Dx: Sleep deprivation

related to uncomfortable sleep environment.

Goal: To regain normal sleep pattern after 1 day.

Outcome: To enable pt. to sleep properly and adequately within 1 day.

INTERVENTIONS EVALUATION

1. Promote a quiet and calm environment to promote rest.

Able to sleep undisturbed as repoted

2. Advised to lessen periods of watching TV.

Able to spend more time on sleeping than on wayching TV.

3. Advised to turn on the lights and other things that can disturb sleep.

Able to sleep in the dark.

4. Encouraged to drink milk before sleeping

Able to drink milk before sleeping and had slept well

• Problem # 5Nursing diagnosis: Risk for

ineffective airway related to physical immobility.

Goal: Maintain airway patency within the shift.

Outcome: To prevent accumulation of secretions on the trachoebronchial tree which obstructs the airway within the shift.

INTERVENTIONS EVALUATION

1.Assisted to turn to sides every 2 hrs.

Any signs of accumulating secretions in the ytracheobronchial tree not noted.

2. Back kept dry Any signs of accumulating secretions in the ytracheobronchial tree not noted.

• Problem # 6Nursing diagnosis: Risk for fall r/t impaired

physical mobilityGoal: To modify environment as indicated to

enhance safety within the shift.Outcome: To avoid fall accidents and injuries

within the shift.

INTERVENTIONS EVALUATION

1. Instructed the folks to always use the side rails..

Fall accident prevented.

2. Assisted pt. on positioning. Pt. postioned properly without fall accidents

3. Placed pt. in a comfortable position

Kept rested

4. Support affected areas with pillows or foot boards

Able to rest with comfort

Problem # 7Nursing diagnosis: Risk for

impaired skin integrity r/t physical immobility

Goal: To maintain skin integrity and prevent lesions or break in the skin .

Outcome: To prevent lesions or break in the skin within the shift..

INTERVENTIONS EVALUATION

1.Maintain meticulous skin hygiene

Patient is able to maintain skin hygiene.

2.Massage bony prominences and use proper positioning, tuning, lifting and transferring techniques when moving client.

No injury occurred during positioning.

3.Keep bedclothes dry and wrinkle free.

Bedclothes are dry and wrinkled free.

4.Repositioning every 2 hrs. Patient is repositioned every 2 hours.

Problem # 8Nursing diagnosis: Risk for

constipation r/t physical mobility.

Goal: To maintain usual pattern of bowel functioning.

Outcome: To maintain usual pattern of bowel functioning within the shift.

INTERVENTIONS EVALUATION

1 Assist and encourage to participate in ROM exercises.

Patient participated in ROM exercises.

2. Increase oral fluid intake.

Patient is able to increase oral fluid intake.

3. Advise High fiber diet. Patient consumed his meals .

• Problem # 9• Nursing diagnosis: Nursing Dx:

Impaired physical mobility r/t neuromuscular impairment

• Goal: To be able to participate in ADL’s and ROM exercises .

• Outcome: To maintain skin integrity within the shift.

INTERVENTIONS EVALUATION

1 Support affected body parts using pillows and foot support.

Patient is able to support affected body parts using pillows and foot support.

2. Provide regular skin care to include pressure area management.

Patient maintains skin integrity.

3. Provide adequate rest periods.

Patient able to rest adequately.

• Problem # 10• Nursing diagnosis:

Ineffective therapeutic Regimen management r/t economic difficulties

• Goal: Identify use available resources within 2 days.

• Outcome: To use available resources within 2 days.

•

INTERVENTIONS EVALUATION

Provided information encourage client and family to seeked out resources on own.

Patient and family is able to choose alternative ways.

Emphasizes importance of client knowledge and understanding of the need for the treatment and medication as well as the consequences of choices and actions

Patient and family is aware of the consequences of not the following the therapeutic treatment modalities.

ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

Subjective:“Indi niya mahulag ang wala niya nga lawas” as verbalized by the folksObjective:(+) left sided weaknessFunctional level of two

Impaired physical mobility r/t neuromuscular impairment

To be able to participate in ADL’s and ROM exercises within the shiftTo maintain skin integrity within the shift

Assist client reposition self on bed or side by side every 2 hoursInstruct in use of side rails for position changesSupport affected body parts using pillows and foot supportProvide regular skin care to include pressure area managementEncourage participation in self care, diversional/recreational activitiesProvide adequate rest periodsPerform and let the patient participate on ROM exercisesProvide safety measures including environmental management and fall preventionEncourage adequate intake of fluids/nutritious foods

To maintain position of function and reduce risk of pressure ulcersTo prevent pressure ulcersTo reduce fatigueTo maintain and exercise muscletoneto ensure safety

Goal met. Patient able to participate to ROM exercises willingly and intact integrity maintained.

ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

SUBJECTIVE:

“Nabudlayan sya

maghambal kay indi ya

mayad mabuka iya

baba kag indi mayad

maintindihan iya nahala”

as verbalized by the folks

OBJECTIVE:Left sided weakness

Slurred speech

Impaired verbal

communication r/t

neurologic impairment.

Enable to express

feelings and thoughts

non-verbally within the

shift.

Encourage him to

express himself non-

verbally through

making signs if speech is

not well understood by the folks.Encourage

the family to talk to the

patient and ask

questions of his

preference.

It enables the patient to express

himself in an alternative mediumThese

practices non-verbal

communication skills of the patient and also promotes

understanding between

him and the family.

Goal metAs evidenced

by pt. learning to

communicate herself through making signs.

“Nagasenyas na sya kun

may gusto sa ipa-ubra o

may indi sya gusto kag indi namun

maintindihan iya

nahambal” as verbalized by

the folks

Assessment Diagnosis Planning Intervention Rationale Evaluation

O-hemiplagiaInability to wash bodyInability access bathroomInability to put clothing on and removing clothingInability to obtain clothingInability to get to the toilet

Self Care Deficit related to neuromuscular impairment.

Demonstrate techniques/lifestyle changes to meet self care needs within the shift.

Determine age.

Promotes client’s participation in problem identification and desired goals and decision making.

Assist with meeting client’s need when he or she is unable to meet own needs.

To determine ability of individual to participate in own care.Enhances commitment to plan, optimizing outcomes, and supporting recovery and health promotion.To determine and promote ability of individual to participate in own care.

Goal not met. A s evidenced by patient did not demonstrate techniques/lifestyle changes to meet self care needs.

Assessment Diagnosis Planning Intervention Rationale Evaluation

S” Indi ako matulugan kung gab-i” as verbalized.O-day time sleepiness

Sleep deprivation related to uncomfortable sleep environment.

Report improvement in sleep pattern within 1 day.

Determine clients usual sleep pattern.Promote client to rest.Suggest abstaining daytime naps.Limit evening oral fluid intake.Keep environment quiet.

Provide comparative baseline.To prevent fatigue.To avoid impairing ability to sleep at night.To reduce night time urination.To promote sleep.

Goal met. As evidenced by patient report improvement in sleep.

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

S: “wala pa kami bulong kay wala pa kami kwarta” as verbalize by folksO: failure to

include regimens

some meds are not available prior to administration

Ineffective therapeutic Regimen management r/t economic difficulties

Identify use available resources within 2 days

Provide information / encourage client and family to seek out resources on own.

Emphasize importance of client knowledge and understanding of the need for the treatment and medication as well as the consequences of choices and actions

To make the pt. and family aware of their choices and alternative ways

To make pt. and family aware of the consequences of not the following the therapeutic treatment modalities

Goal partially met.As evidenced by the family understtod the importance of following therapeutic management and knows other resources but still unable to provide all the needed medications.

ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

Subjective:Objective:(+)left sided weakness

Risk for fall r/t impaired physical mobility

To modify environment as indicated to enhance safety within the shift.To avoid fall accidents and injuries within the shift.

Instruct family the use of side rails.Assist Pt. in position changes and in any desired actions.Place pt. in a comfortable position.Support affected areas with pillows or foot board.

To avoid fall accidents and to promote pt. safety.To avoid any injuries.To promote restTo minimize discomfort.

Goal met. As evidenced by no fall accidents or injuries has occurred within the shift.

ASSESSMENT NURSING DIAGNOSIS

PLANNING INTERVENTIONS

RATIONALE EVALUATION

Subjective:“indi nya

mahulag iya wala nga

lawas kag indi sya

kabangon” as verbalized of

the folksObjective:

(+) left sided weakness

Risk for constipation r/t physical

mobility.

To maintain usual pattern

of bowel functioning within the

shift.

Assist and encourage to participate in

ROM exercises.

Increase oral fluid intake.Advise High fiber diet.

To facilitate exercise.To soften

stool.To facilitate regular BM.

Goal Met as evidenced by normal BM within the

shift.

ASSESSMENT NURSING DIAGNOSIS

PLANNING INTERVENTIONS RATIONALE EVALUATION

Subjective:“indi nya mahulag iya wala nga lawas” as verbalized of the folksObjective:(+) left sided weakness

Risk for impaired skin integrity r/t physical immobility

To maintain skin integrity and prevent lesions or break in the skin within the shift

Maintain meticulous skin hygiene Massage bony prominences and use proper positioning, tuning, lifting and transferring techniques when moving client.Keep bedclothes dry and wrinkle free.Provide preventive skin care.-Change diapers regularly-cleanse perineal careRepositioning every 2 hrs.

To prevent friction or shear injuryTo prevent irritationTo minimize contact with irritants such as urine and stool.To prevent pressure sores.

Goal Met as evidenced by no presence of lesions or break in the skin integrity is noted at the end of shift.

ASSESSMENT

NURSING DIAGNOSIS

PLANNING INTERVENTION

RATIONALE EVALUATION

SUBJECTIVE:“Pirme lang

basa ang likod nya” as

verbalized by the folks

OBJECTIVE:(+)left sided weaknessBed-ridden

Risk for ineffective

airway related to physical immobility.

Prevent having ineffective

airway related to immobility

within the shift.

Reposition the patient into side-lying

position every 2 hours.

Keeping the back dry.

Repositioning every 2 hours prevent the

sweat to stay on the back a

long time therefore

reducing the risk for

ineffective airway.

Keeping the area always dry prevent excessive

moisture and prevent the sweat from

drying into the patient’s back.

Goal metAs evidenced by no signs of

ineffective airway within

the shift.“wala man sa

naubo o nasip-on” as

verbalized by the sister.

DISCHARGEPLANNING

DISCHAGE PLANNINGMEDICATION· Encourage the client to comply with all the

prescribed medications.· Emphasize to the client and her family of the

importance of taking the medications at the prescribed schedule, dosage and frequency.

· Educate the client about the purpose of the drugs.· Advice the significant others not to leave the client

during medication to secure that the client has taken the medicines.

· Explain to the client the side effects and adverse effects of the drug she takes by describing its manifestations. Client and significant others should be aware so that prompt medical intervention can be given if in case such reactions occur.

Rationale:Client and significant others must know and understand

the drug’s generic and brand name, dosage, route, frequency, purpose and side effects for them to be knowledgeable in administering the drug and to avoid any accidents regarding drug administration. And for the significant others to know how important they are in contributing to the healing process of the client.

Home medication:• Telmisartsan/HCT2 (micardis plus) 40g 1 tab

TID• Trimetazidine (vestar) 35g 1 tab BID• Moxifloxacine (avelox) 400g 1 tab OD• Allopurinol (allurose) 300g 1 tab OD• Amlodipine (norvase) 5g 1 tab OD• Zynapse 2.5mg ml BID• Hytrin 2mg ½ tab @ HS• Catapres/atepras 5mg 1 tab OD

EXERCISE· Encourage to ambulate and assume her normal activities as

long as there will be no problems.· Instruct client to have frequent arm exercise· Educate the

client on proper body mechanics to enable her to relax, be comfortable and prevent strains.

· Instruct the client to balance activities with adequate rest periods.

Rationale:• Exercise is now also known to be major contributor to health

and can improve the body in three ways: through increased stamina; more efficient heart, lungs, and circulatory system, improved muscle tone, through enhanced strength; and more supple joints. It is also essential to prevent obesity and to help control weight.

• HYGIENE· Instruct the family to do proper personal hygiene

such as taking a bath daily, brushing her teeth after eating and proper grooming.

· Encourage the client as well as the significant others to follow physician’s instructions regarding personal hygiene and self care.

Rationale:It is essential to both the client and the significant

others to have a hygiene and healthy lifestyle in order to promote faster recovery and prevent causing further injury and damage to the client.

TREATMENT· Educate the client on the importance of drug and money

compliance.· Discuss to the client the complication of the condition because

knowledge about the condition supports learning that will decrease anxiety.

· Instruct the client to report or ask medical assistance when abnormalities occur.

· Educate the family on how to demonstrate a correct performance of the treatment.

• Rationale:It is important for the client, including the family, to know the

importance of drug or treatment compliance in order to achieve an effective outcome and facilitate continuous care.

• DIETEncourage the folks to provide the

patient nutritious and clean foods such as fruits, vegetables, and others according to her age. Avoid foods and water that are not prepared well or unsanitary. Avoid foods in high cholesterol.

• OUT-PATIENT REFERRALS· Instruct the patient to comply with the scheduled

follow up check up to enable the physician to have continuous record on the client’s condition.

· Advice the client to report any abnormalities observed to provide immediate medical intervention.

• Rationale:Regular check-up or consultation with a physician

provides continuous update on the client’s condition. With the physician’s medical intervention and the client’s cooperation, faster recovery can be obtained.

SPIRITUALITY· Encourage client to strengthen hisfaith with Almighty

Father to provide spiritual growth and promote healing.· Advice client never to forget God, to ask for Jesus’ help

and to\ believe in the healing power of the Holy Spirit to promote peace of mind and relaxation, thus promoting comfort and healing not just to the mind but also to avoid harm and promote a soothing and pleasant atmosphere with everyone.

• Rationale:It is important to take care of the spiritual aspect of the

client because it is one of the many factors that could promote healing to the physical aspect, the body, but also to the client’s spirituality and the mind.

SEXUALITY· Inform the client that there is a breadth and depth of

sexual expression possible and that she is a person of value.

· Recognize the feelings of warmth, approval, and friendship, as well as sharing and touching, are important.

• Rationale:Sexuality is part of a person’s self-concept and involves

feelings of self-worth, acceptance, sharing, affection and intimacy, as well as feelings of femininity. It includes physical, psychological, emotional, and social elements and is reflected in everything a person says and does. It also promotes to the healing process of the client.