CVD Case Press

Biographic Data:

Patient X was admitted on September 21, 2010 at 11:00 pm at PDMMMC. Patient X who is male, 67 years of age, Married, Roman Catholic, Filipino is presently residing at Caloocan City.

Nursing Health History:

Chief Complaint:

PTA patient suddenly developed LOC; he then noted weakness of his left side of the body.

Past illness history:

As verbalized by his wife he have no past history illness. This was the first he admitted to the hospital.

Family history illness:

Hereditary of both side’s mother and father

(+) hypertension

Present illness history:

Patient was diagnosed (+) Hypertension and (+) DM

Lifestyle:

(+) Smoking (1 ½ pack of cigarettes a day)

(+) drinking (beer twice a day, Moring and evening)

Gordon’s Functional Health Patterns

Past History Present HistoryNutritional-Metabolic Pattern - Usual eating pattern “3 meals

a day- Prepares to eat more on

vegetables and high sodium(dried fish,grilled pork) and fatty foods(balot, nilagang baka,chicaron,crispy pata)

- Ostiorized feeding through NGT with low salt low fat diet.

Elimination Pattern - Has no problem on elimination

- Urine output of approximately 1,300ml per day

- With Foley catheter connected to urine bag with dark yellow urine output(1,100ml)

- Involuntary passage of stool characterized by loose, liquid stool elimination(150mg)

- Changes diaper 4 times a dayCognitive-Perceptual pattern

- Responds appropriately to verbal and physical stimuli

- PTA, disoriented to time and place

- Difficulty of breathing- slurring of speech- Inability to move right

half/side of the bodyActivity-Exercise pattern - No particular habits of

exercise- Usually consumes 1 ½ packs

of cigarette per day- Drinks regularly 2 bottles of

liquor

-Complete bed rest

Sleep-Rest pattern - Irregular sleep when at home consumes only 5-6 hours of sleep

- Inadequate rest

- Fell asleep for 1-2 hours- When awake, appears

agitated and restless due to administration of nasal cannula

Physical Assessment

Normal Findings Actual Findings Remarks

SKIN

Color and pigmentation

Moisture Temperature

Mobility and turgor

Light to deep brown

Moist

The skin springs back to its previous state after being pinched

Pallor

Hot and Dry

The skin slowly returns back to its previous state after being pinched

Impaired Circulation

Fever

Old Age

NAILS

Nail bed color

Capillary refill

Pink

capillary refill (1-3secs)

Pale

delayed capillary refill (4 secs)

Impaired Circulation

Impaired Circulation

FACE

Skin color

Light to deep brown Pale Impaired Circulation

EYES

Conjunctiva Pink conjunctiva Pale palpebral conjunctivae

Decreased tissue perfusion

MOUTH & PHARYNX

Lips

Color

Moisture

Pink

Moist

Pale

Dry

Poor

Circulation

Poor Hydration

Tongue

Position Left lateral(slurred speech)

Left lateral position Slurred speech

abnormal

Teeth No cavities Some Teeth Missing (smoker)Some with cavities

halitosis

Poor Oral Care

NECK

Range of movements Smooth movements without discomfort

Symmetric and at midline position

Restricted movements with discomfort Symmetric and at midline position

Due to Muscle Weakness and numbness

THORAX

Lungs No tenderness

No adventitious sound

Rales, crackles sounds Due to pneumonia

HEART

Rate Normal(60-100) Abnormal(120bpm) Increased rate due to Infection

UPPER AND LOWER EXTREMITIES

NORMAL FINDING ACTUAL FINDING REMARKS

SKIN COLOR Light to deep brown Bluish discoloration Impaired circulation

LABORATORY EXAMINATION

HEMATOLOGY

SEPTEMBER 22, 2010

RESULT REFERENCE REMARKS

HEMATOCRIT 0.37 0.40-0.51 Blood loss

HEMOGLOBIN 131 135-180g/L Blood loss

RBC COUNT 4.11 50-6.5x10-12g/L Blood loss

WBC COUNT 12 4.5-11.0x10g/L Infection

NEUTROPHILS 0.85 0.50-0.70 Infection

LYMPHOCYTES 0.15 0.20-0.40 infection

SEPTEMBER 23, 2010

RESULT REFERENCE REMARKS

WBC 13 4.5-11.0x10g/L Increase WBC

RBC 3.5 50-6.5x10-12g/L Anemia

SEPTEMBER 23, 2010

CHEMISTRY RESULT UNIT REMARKS

SODIUM (ISF) 140.50mmol/L 135-148 Normal

POTASSIUM (IST) 3.36mmol/L 3.50-5.30 Hypokalemia

HEMOGLUCOSE TEST

SEPTEMBER 22, 2010

6:00PM (before meal)

RESULT REFERENCE REMARKS

129mg/dl 70-110mg/dl Hyperglycemic

SEPTEMBER 27, 2010

12 PM(before meal)

RESULT REFERENCE REMARKS

151mg/dl 70-110mg/dl Hyperglycaemic

LABORATORY EXAM

CHEST X-RAY RESULT:

RIGHT POSTERIOR INFILTRATES PNEUMONIA

SLIGHT LEFT VENTRICULAR CARDIOMEGALY

BONY THORAX IS INTACT

CT SCAN

ACUTE INTRAPARENCHYMAL HEMATOMA IN THE LEFT BASAL GANGLIA

MEDICATION

Brand Name/Generic

Name

Dosage for

Patient

Action Indication Contraindication Adverse Effect Nursing Responsibilities

CEFTRIAXONE

Cephalosporin, third generatio

2grams as initial dose then OD (-) ANST.

Inhibit cell wall synthesis promoting osmotic instability visually bactericidal

Lower respiratory tract infections, due to staphylococcus aureus and stertococcus pnuemonae.

Hypersensitive to drug

Diarrhea, Rash, eosinophilia, nausea, pain/induration tenderness warmth at injection site

Do not mix drugs with other antibiotics.

Maintain dosage for at least 2 days after symptoms have disappeared.

Brand Name/Generic Name

Dosage for

Patient

Action Indication Contraindication Adverse Effect

Nursing Responsibilities

ATORVASTATIN

Antihyperlipidemic

AMG – coA reductase inhibitor

80mg / tab

½ tab OD @ HS.

Competitively inhibits AMG – coA reductase, this enzymes

Adjunct to diet to decrease elevated total and LDL cholesterol, apo B and triglyceride is primary

Active liver disease or unexplained persistently high LFT’s. Use with grapefruit juice.

Headache, Paresthesia, Asthenia, Insomnia

Give as a single dose anytime with or without food.

catalyzes the early rate – limiting step in the synthesis of cholesterol. Thus, cholesterol synthesis is inhibited or decreased.

hypercholesterolemia.

Determine lipid levels within 2-4 weeks. Adjust dosage accordingly.

Brand Name/Generic

Name

Dosage for

Patient

Action Indication Contraindication Adverse Effect

Nursing Responsibilitie

s

CLINDAMYCIN

Antibiotic,

Lincosamide

300 mg 1 tab TID

Suppresses protein synthesis by micro organisms by binding to ribosomes and preventing peptide bond formation. It’s both bacteriostatic and bacteriocidal.

Serious infection caused by susceptible strains of streptococci, pneumococci , stapyloccoci and anaerobic bacteria.

Hypersensitivity to either clindamycin or lincomycin.

CV: hypotension,

Thrombophlebitis

If significant diarrhea occurs and report to physician.

Brand Name/Generic

Name

Dosage for

Patient

Action Indication Contraindication Adverse Effect

Nursing Responsibilities

LOSARTAN

Anti hypertensive angiotensin II receptor

50 mg / tab OD

Inhibits vasoconstriction and aldosteron secreting action of angiotensine to receptor on

Antihypertensive, alone or in combination with other antihypertensive

Contraindicated to patient hypertensive to drug

CV: Angina pectoris, vasculitis.

No initial dosage adjustment is needed for the elderly or for those with renal impairment,

blocker. the surface of vascular smooth muscle of other cell

drugs.

Reduce risk of stroke in clients with hypertension and left ventricular hypertrophy

including those on dialysis.

Brand Name/Generic

Name

Dosage for

Patient

Action Indication Contraindication Adverse Effect Nursing Responsibilities

MANNITOL

Diuretic, osmotic

100 cc / IV every 6 hours

Increases the osmolarity of the glomerular filtrate, which decreases the reabsorption of water and increases excretion of

Decrease ICP and cerebral edema by decreasing brain mass.

To promote urinary excretion of toxic

Anuria, pulmonary edema, severe dehydration, active intracranial bleeding, except during craniotomy, progressive renal damage following mannitol therapy

CV: edema, hypo/hypertension, increased heart rate, angina like chest pain, CHF, Trombophlebitis

Use a filter with concentrated mannitol (15%, 20%, and 25%)

Concentration > 15% may crystallize.

Do not add to other IV solutions

sodium and chloride. It also increases the osmolarity of the plasma, which causes enhanced flow of water from tissues into the interstitial fluid and plasma

substance.

or mix with medications

Brand Name/Generic

Name

Dosage for Patient

Action Indication Contraindication Adverse Effect Nursing Responsibilities

RANITIDINE

Histamine H2 receptor blocking drug

50 mg / IV every 8 hours

Competetively inhibits action of histamine on the H2 at the receptor sites of parietal cells decreasing gastric acid secretion.

Treatment of endoscopically diagnosd erosive esophagitis and for maintenance of healing of erosive esophagitis.

IV – Prevent paclitaxel hypersensitivity; reduce the incidence of GI hemorrhage associated with stress related ulcers

Cirrhosis of the liver, impaired renal or hepatic function

Headache

Abdominal pain

Constipation

The premixed infection does not require dilution; give by SLOW IV drip over 15 – 20 minutes.

Do not introduce additives into the solution.

Undiluted ranitidine injection tends to manifest a yellow color that may intensify over time without adversely potency

Brand Name/Generic

Name

Dosage for

Patient

Action Indication Contraindication Adverse Effect Nursing Responsibilities

SALBUTAMOL Anti-asthma

1 neb every 6 hours

Relaxes bronchial uterine and vascular smooth muscle by stimulating Beta 2 receptor.

Prevent/treat bronchospasm in patient with reversible obstructive airway disease.

Hypersensitivity Precaution:

Hyperthyroidism

DM

Cardiovascular disease

Adverse reaction: Fine tremor of skeletal muscle feeling oftension a compensary small increase in heart rate, headache, muscle cramps

Assess condition before therapy and reassess regularly thereafter to monitor drug effectiveness.

Brand Name/Generic

Name

Dosage for

Patient

Action Indication Contraindication Adverse Effect

Nursing Responsibilities

CITICOLINE

CNS Stimulant

1 g / IV every 12 hours.

Citicoline is an internueronal communication enhancer. It increases the neuro transmission levels because it favors the synthesis and production speed of dopamine in the stratum.

CVD in acute and recovery phase.

Parasympathetic hypertonia

Insomnia, headache.

Somazine must not be administered along with medicanents containing medophenoxate.

Brand Name/Generic

Name

Dosage for

Patient

Action Indication Contraindication Adverse Effect

Nursing Responsibilities

Paracetamol

(Biogesic)

500mg q4

Unknown. thought to produce analgesia by bocking pain impulses probably by inhibiting synthesis of prostaglandin in the CNS or other at substance t

Mild pain or fever

Hypersensitive to drug

Rash Use cautiously in patient with history of chronic alcohol use because of hepatotoxicity.

REVIEW OF SYSTEM

• Nervous system

1. Brain

-left brain paralysis

← -speech problem

← -blurring of vision

← -level of consciousness(decrease)

2. Nerves

- Damage in the cranial nerves particularly in

Optic Nerves

Blurred vision

, Trigeminal Nerves

Numbness of sensation

Facial Nerves

Loss of motor activity

, Vagus Nerves

Accessory Nerves

,

Hypoglossal Nerves

Slurring of speech

- Loss of sensation in right upper and lower extremities or unilateral or bilateral part of the body

3. Spinal Cord

-loss of sensation and motor

-loss of homeostasis

-paralysis

• Respiratory System

1. Lungs

- Pneumonia

- Chest pain

- cough with phlegm

- rales or crackles sound

2. Diaphragm

- Difficulty of breathing

• Musculoskeletal System

1. Muscles

-weakness of face muscles

-loss of motor movement

-Weakness of body muscles

2. Bones

-activity intolerance

-immobility

• Circulatory System

• Blood

-blood clot

-increase blood pressure

• Digestive system

• Salivary glands

-difficulty of swallowing/chewing

- Incapable of eating by mouth

ANATOMY

&

PHYSIOLOGY

←

PATHOPHYSIOLOGY

Sign and symptoms:

- Flaccid paralysis- Spastic paralysis- Coma- LOC Frontal:- Contralateral

muscle weakness or paralysis

- Sensory loss in legs Middle cerebral

artery- Contralateral

Paralysis- Sensory Loss- Aphasia Occipital- Visual loss

Complication:

Pneumonia

Aspiration

Constipation

Contractures related to paralysis