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