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LYCEUM OF THE PHILIPPINES UNIVERSITY COLLEGE OF NURSING

A CASE STUDY ON CEREBROVASCULAR ACCIDENT

PRESENTED BY: DE CHUSA, GAZELLE B. DE LOS SANTOS, SHARMANE AINA D. DEL MUNDO, ROSSE L. ENDOZO, CHRISANDRA M. FALTADO, MARY JANE E. GABAY, RACHEL MARIE T. GARCIA, PAULYNE KRISELLE M. HERNANDEZ, JOHN MICHAEL H. MARCOS, KRISCELE V. YACO, ANN ZENITH L.

BSN III-2

TABLE OF CONTENTS

I. II. III. IV. V. VI. VII.

INTRODUCTION OBJECTIVES PATIENTS PROFILE CLINICAL APPRAISAL PHYSICAL ASSESSMENT DIAGNOSTIC AND LABORATORY RESULTS ANATOMY AND PHYSIOLOGY

VIII. PATHOPHYSIOLOGY IX. X. XI. XII. NURSING CARE PLAN DRUG STUDY PROGNOSIS DISCHARGE PLANNING

XIII. ACKNOWLEDGEMENT XIV. REFERENCES

I. INTRODUCTION Cerebrovascular Disorders is an umbrella term that refers to a functional abnormality of the central nervous system (CNS) that occurs when the normal blood supply to the brain is disrupted. Strokes can be divided into two major categories: ischemic, in which vascular occlusion and significant hypoperfusion occur and hemorrhagic, in which there is extravasation of blood into the brain or subarachnoid space. Ischemic stroke, cerebrovascular accident (CVA) or brain attack is a sudden loss of functioning resulting from disruption of the blood supply to a part of the brain. This is subdivided into five different types based on the cause. The small penetrating artery thrombotic strokes (25%), Large artery thrombotic strokes (20%). The cardiogenic embolic strokes (20%) are associated with cardiac dysrhythmias, usually atrial fibrillation. It can be associated with valvular heart disease and thrombi in the left ventricle. Emboli originate from the heart and circulate to the cerebral vasculature, most commonly the left middle cerebral artery, resulting from stroke. The cryptogenic strokes (30%) which have no known cause and strokes from other causes, such as illicit drug use, coagulopathies, migraine and spontaneous dissection of the carotid or vertebral arteries.(Smeltzer, Bare, Hinkle & Cheever, 2010) An ischemic stroke can cause a wide variety of neurologic deficits, depending on the location of the lesion (which the vessels are obstructed), the size of the area of inadequate perfusion and amount of collateral (secondary or accessory) blood flow. The patient may present with any of the following signs o symptoms: Numbness or weakness of the face, arm or leg, especially one side of the body; Confusion or change in mental status; trouble speaking or understanding speech; visual disturbances; difficulty walking, dizziness, or loss of balance or coordination and sudden severe headache. Motor, sensory, cranial nerve, cognitive, and other functions may be disrupted. In right hemispheric stroke the following can be observed paralysis or weakness on left side of the body, Left visual field deficit, spatial-perceptual deficits, increased distractibility, impulsive behavior and poor judgment lastly lack of awareness of deficits. Risk factors can be broadly classified into controllable and uncontrollable risks. The controllable risks include smoking, hypertension, carotid or other arterial diseases, history of Transient Ischemic Attack, Diabetes, High Cholesterol, physical inactivity, obesity, alcohol, drug abuse and injury to brain. According to National Statistics Office reported by Abs-Cbn news last October 20, 2011, Cerebrovascular Disease became second cause of death among Filipinos, with 56,670 people dying of the illness from January 20092010. Stroke, which is second to heart attack as the leading cause of death in the Philippines, also affects young people as a result of birth or congenital defect based on newsinfo.inquirer.net. Moreover, we chose this case because we are interested to know the factors that contribute to the disease and its pathohysiology. We also wanted to enhance our knowledge, skills and attitude in handling patient with this disease including the independent nursing care that we may render to the patient.

II.

OBJECTIVES The completion of this case study aims to equip the student nurses with

knowledge, skills and attitude necessary to form critical nursing abilities in rendering care to the client in need. The student nurses will enhance their affective, cognitive and psychomotor aspects through the formulation of nursing care process.

Specific objectives: Familiarize themselves in Cerebrovascular Accident, its associated clinical manifestation, and its incidence rate for better understanding of the disease process. Discuss the patients profile (including the date of admission, physician, chief complaint, admitting and final diagnosis), past and current health history, family, personal, social, and psychological history as reference for clients health status. Conduct physical assessment to assess the general appearance, consciousness and cognition, to examine the cranial nerves, motor system, sensory system and reflexes of the patient. Analyze, interpret and relate the results of conducted laboratory and diagnostic test. Understand the anatomy and physiology of related organs. Explain the cause and process of the disease or its pathophysiology and the signs and symptoms manifested by the patient. Formulate and provide an efficient nursing care plan for the improvement of the patients health status utilizing nursing process. Carry out necessary nursing interventions appropriate for the provision of patient care. Discuss the drugs taken by the patient with their corresponding doses, frequency, routes, classification, action, indications, contraindications, side-effects, nursing responsibilities and monitoring parameters. Provide information on the prognosis of the patient Create an appropriate discharge plan for the patient. Learn new clinical skills with regards to the prevention, treatment and management of the disease. Develop a sense of understanding to our patient by providing nursing care holistically Appreciate the improvements made by the patient and family. Practice compassion and competence in the care of client with Cerebrovascular Accident.

III. PATIENTS PROFILE NAME: Patient RA AGE: 67 years old ADDRESS: Ibabao, Cuenca NATIONALITY: Filipino RELIGION: Roman Catholic GENDER: Male STATUS: Married DATE OF ADMISSION: January 20, 2013 HOSPITAL #: 092873-2 PHYSICIAN: Dr. Leynes ADMITTING DIAGNOSIS: T/C Cerebrovascular Large Frontotemporoparietal infarct left, probably cardioembolic >HASCVD (Hypertensive Aterosclerotic Cerebrovascular Disease)

DATE OF DISCHARGE: February 2, 2013 SOURCE OF INFORMATION: Jennie Carandang (daughter)

CHIEF COMPLAINT: right sided body weakness and inability to speak

IV. CLINICAL APPRAISAL GENERAL SURVEY Received patient lying in bed, appears weak and has difficulty speaking. With number 15 PNSS 1L hooked at left metacarpal vein infusing at 80cc/hr. Age is in accordance with his physical development. He is dressed in hospital gown. The client opens his eyes spontaneously upon hearing his name. He answers to questions but with incomprehensible sounds. On the other hand, he would have wanted to obey commands if not with the presence of his right side body weakness. Otherwise, he can move his left extremities effortlessly PAST HEALTH HISTORY Patient RA has no known allergies on food or drugs. According to his wife, he had vehicular accident on 1993 where he needed to stay in the ICU at Greece for almost a month. With regards to this event, he went through several treatments since tests revealed contusion of his chest and pneumothorax. Whenever encountering an illness, they have made it a habit to just take overthe-counter drugs like Biogesic for headache, Paracetamol for fever, Neozep for colds and the like. The second was in June 8, 2013 when he spent four days at the same institution (MMMC) due to diverticulosis. The relatives was not able to recall the management done. Patient RA has a maintenance drug of Approvel 300 mg once a day for his hypertension. FAMILY HISTORY Patient RA has a family history of hypertension as well as his wife. His parents both died with age alongside with cardiovascular disease. And it has been apparent to them that he is prone to either of the two CVDs cardiovascular disease and cerebrovascular disease since these are prominent on both of his parents side. PERSONAL HISTORY He is currently residing at Cuenca Ibabao after 20 years of living in Greece with his 57 year old wife and where he also worked as a driver. He usually includes meat (chicken, pork) in his meals and is not satisfied if not paired with 5-6 cups of rice. He also eats vegetable and fruits whenever present at the table. Walking early in the morning is his form of exercise. His urine, bowel and sleeping pattern were normal. Patient RA is a chain smoker. He started smoking when he was 16 and consumed 1 pack of cigarette a day. He was also

addicted to alcohol. He could consume 15 bottles of alcohol like beer, red horse. emperador and the like with company on occasion, once to thrice every week. Last year, he decided to stop his vices. SOCIAL HISTORY Patient RA is a Roman Catholic. According to his wife they are exposed to noise and air pollution because they are residing near the national high way. They are living harmoniously with their relatives and neighbors. Patient RA belongs to a nuclear type of family. The family believes in quack doctors and consults to it whenever one member of the family is ill. Patient RA is an elementary graduate. He joins in programs of their barangay especially if it talks about health. PSYCHOLOGICAL HISTORY There has been no incident of mental retardation in patient RAs line of family. His typically gets stressed financially and due to some misunderstandings with his wife. He can easily bend into problems by patching things up with his wife. HISTORY OF PRESENT ILLNESS Hours prior to admission, almost midnight of January 20, 2013, he was rushed to MMMC due to aphasia and right sided body weakness. He lost consciousness in the ER and was admitted at ICU for 3 days. Morning of January 23, 2013, he was transferred to medical ward with a diagnosis of T/C cerebrovascular disease large Frontotemporoparietal infarct left, probably cardioemolic HASCVD.

V. PHYSICAL ASSESSMENT Date General Appearance January 28, 2013 Received patient lying in bed, appears weak (lacks strength and energy to do something, cant stand) hooked with IVF of # 15 PNSSIL@80cc/hr. His age is in accordance with his physical and sexual development. He dresses appropriately to weather. The client opens his eyes spontaneously upon hearing his name. He answers but with incomprehensible sounds, slurring speech, and he obeys command. He has a Glasgow Coma Scale of 12 with a score of 4 on Eye opening, 2 on Verbal Response and 6 on Motor Response. BP: 140/90 mmHg Temperature: 36.6oC Respiratory rate: 21 breaths/min Pulse rate: 75 beats/min Methods Findings Analysis Inspection -light brown in -Normal color - few scars were -Abnormal due to noted on lower previous vehicular extremities accident. Palpation -warm to touch -Normal -intact skin -Normal -Returns to its -Normal position when pinched. Inspection -White hairs was -Normal, due to noted aging Palpation - Free from -Normal masses, lumps, scar, dandruff and lesions, no areas of tenderness. Inspection -with clean nails -Normal Palpation -capillary refill test -Normal returns immediately on both hands Inspection -Located in -Normal midline, no involuntary movements, still and upright -Asymmetric facial -Abnormal, Due to features when CN VII damage smiling, frowning, and puffing up cheeks. Palpation -No sensation felt -Abnormal due to on the left side of CN V damage the face either blunt or sharp. Inspection -Neck is -Normal symmetric, without bulging masses or

Vital signs

Body parts

Skin

Hair Scalp

Nails

Head/ Face

Neck

Palpation

Auscultation Inspection

Eyes

Palpation Inspection

Ears

Palpation

any enlargement. -unable to swallow -Abnormal due to impairment of CN X. - No enlarged and -Normal tender lymph nodes - No bruits heard -Normal - Parallel and -Normal evenly placed, symmetrical not protruding. - No presence of -Normal redness and swelling - Cornea is -Normal transparent with no opacities; iris is round, flat and evenly colored. - Pupil equally -Normal round -Iris is round and -Normal flat and evenly colored. -Has no blink -Abnormal due to reflex on left side CN V damage. of eyes -pupil has no -Normal constriction to light on left side of the -Abnormal due to eyes. CN III damage. -pupils do not constrict on left -Abnormal due to side; eyes do not dysfunction of converge. cranial nerve III -able to follow the and IV six field of gazes -Normal on both sides - Sclera is white in color -Normal -Pinkish conjunctiva -Normal -No tenderness on -Normal lacrimal glands. -Color is the same -Normal as the facial skin -Symmetrically -Normal aligned -No redness, -Normal lesions on pinna, tragus or auditory meatus -Small amount of -Normal cerumen present -No tenderness, -Normal

Inspection

Nose Mouth

Palpation Inspection

firm -NGT was inserted on right nose -Symmetrically aligned -No lesions or abrasions noted -No tenderness, - Lips are smooth and moist without lesions or swelling. - Has decayed teeth - Buccal mucosa appears pink. - Tongue is pink and moist with papillae. -unable to protrude tongue and move from side to side. -dysarthria -expressive aphasia -no observed retraction -Has adventitious sounds; crackles heard -Heard heart murmurs

-Abnormal. due to inability to swallow -Normal -Normal -Normal -Normal

-Abnormal due to poor hygiene. -Normal -Normal

Thorax

Inspection Auscultation

-Abnormal due to impairment in cranial nerve IX and XII. -Abnormal due to CN IX damage. - Abnormal due to CN IX damage. -Normal -Abnormal due to accumulation of mucus -caused by blood rushes through the heart quickly during normal function. -Abnormal, Indicate excess body fats deposit -Normal

Heart

Auscultation

Inspection

-round abdomen

Abdomen Auscultation

-umbilical skin tones are similar to surrounding abdominal skin tone. -2-3 bowel sounds heard in 1 mins -no pain

Palpation

-hypoactive due to decreased physical activity -Normal

Musculoskeletal (upper)

Inspection

Palpation

Musculoskeletal (lower)

Inspection

Palpation

-unable to move the right arm -unable to shrug the shoulders -shoulders, arms and elbows are symmetric with no deformities. -muscle strength is 0/5 on right -no tenderness - has intact skin returns to original position after pinched -unable to move the right leg, inability to stand. - muscle strength is 0/5 on right -with grade 1 bipedal edema -has positive Babinski reflex - has intact skin returns to original position after pinched

-Abnormal due to left side stroke -Abnormal due to CN XI damage. -Normal

-Abnormal due to left side infarct. -Normal -Normal

-Abnormal due to left sided stroke -Abnormal due to Left side infarct. -Abnormal, Indicates Fluid Retention -severe damage to the central nervous system. -Normal

SUMMARY OF PHYSICAL ASSESSMENT A head to toe assessment was done last January 28, 2013 10:00 in the morning. Upon receiving the patient, a right sided body weakness was evident on his general appearance. The following are the abnormal findings few scars were noted on Abnormal due to previous vehicular accident. Asymmetric facial features when smiling, frowning, and puffing up cheeks CN VII damage. No sensation felt on the left side of the face either blunt or sharp. He has inability to swallow. He has no blink reflex on left side of eyes. Pupils have no constriction to light on left side of the eyes they do not constrict; eyes do not converge. NGT was inserted on right nose. Has decayed teeth, unable to protrude tongue and move from side to side. Dysarthria and expressive aphasia is present. Upon auscultation, crackles were heard. Abdomen was round and 2-3 bowel sounds heard in 1 mins. He has inability to move the right arm and shrug the shoulders. On upper extremities, muscle strength is 0/5 on right. On lower extremities, inability to move the right leg and inability to stand is present. Muscle strength on right side is 0/5, with grade 1 bipedal edema and a positive Babinski reflex.

VI. LABORATORY / DIAGNOSTIC EXAM RESULTS Date: January 20, 2013 Laboratory Exam WBC HEMATOLOGY Normal Values Result Complete Blood Count 5-11 10^3/uL 13.66 Analysis Increased due to infiltration of inflammatory cells Decreased due to insufficient oxygen Normal Normal Normal Normal Normal Normal Normal Increased which causes excessive blood clotting that leads to stroke Normal Normal Normal Normal Decreased due to infiltration of inflammatory cells

RBC Hemoglobin Hematocrit MCV MCH MCHC RDW-CV RDW-SD Platelet

4.6- 6.2 10^6/uL 13.5- 18 g/dL 40-45 % 80-100 fL 27- 33 pg 31-36 g/dL 11-16% 37-54 fL 150-400 10^3/uL

4.50 14.5 40.3 89.6 32.2 36 14.0 45.9 543

Neutrophil Lymphocytes Monocyte Eosinophil Basophil

0.55-0.77 0.27-0.33 0-0.12 0-0.07 0.01-0.05

0.67 0.18 0.10 0.05 0.00

Date: January 28, 2013 HEMATOLOGY Laboratory Exam Normal Values Result Complete Blood Count WBC 5-11 10^3/uL 9.89 RBC 4.6- 6.2 10^6/uL 4.23 Analysis Normal Due to decrease absorption of nutrients such as iron. Decreased due to insufficient oxygen Decreased due to impaired cerebral blood flow Normal Normal Normal Increased due to excessive blood clotting that leads to stroke Normal Normal Normal

Hemoglobin Hematocrit

13.5- 18 g/dL 40-45 %

13.3 38.3

MCV MCH MCHC Platelet

80-100 fL 27- 33 pg 31-36 g/dL 150-400 10^3/uL

90.5 31.4 34.7 415

Neutrophil Lymphocytes Monocyte

0.55-0.77 0.27-0.33 0-0.12

0.69 0.17 0.05

Eosinophil Basophil

0-0.07 0.01-0.05

0.05 0.09

Normal Increased due to condition that cause inflammation

Date: January 20, 2013 Laboratory Exam Creatinine Sodium HEMATOLOGY Normal Values Result Blood Chemistry 0.80- 1.50mg/dL 0.9 Serum Electrolytes 137-145 mmol/L 135.8 Analysis Normal Decrease due to dilutional hyponatremia or fluid retention. Increased due to counteracting effects of decrease Na.

Potassium

3.5- 5.10 mEq/L

5.3

Blood Coagulation Prothrombin Time Patient 9-13 sec 14.8 Increased which causes blood clotting. Normal Increased which causes blood clotting

Control Platelet

10.3-13.1 sec 150-400 10^3/uL

10.6 543

Date: January 21, 2013 Laboratory Exam Blood Uric acid FBS Triglycerides HDL Blood Chemistry Normal Values Result 0.21-0.50 mmol/L 0.27 75-110mg/dL 86.9 0-150mg/dL 75.3 40-60 mg/dL 33.6 Analysis Normal Normal Normal Decreased may accelerate the development of atherosclerosis because of impaired reverse cholesterol transport and possibly because of absence of other protective effects of HDL. Normal

LDL

0-150 mg/dL

54

Date: January 28, 2013 Laboratory Exam HEMATOLOGY Normal Values Result Analysis

Blood Chemistry Creatinine

70.72-132.60 umol/L

61.88

Decreased due to energy failure and aging. Decreased due to diuretics (Mannitol) given. Normal

Sodium

Serum Electrolytes 137-145 mmol/L 135.8

Potassium

3.5- 5.10 mEq/L 5.00 Blood Coagulation 14.8

Prothrombin Time Patient 9-13 sec

Control Platelet

10.3-13.1 sec 150-400 10^3/uL

10.6 543

Increased which causes blood clotting. Normal Increased which causes blood clotting

Date: January 20, 2013 ABG with Oxygen Normal Values Result 7.35-7.45 7.46 35-45 36 80-90mmHg 136 22-26 27 (-2)-(+2) % 2 95 % or greater 99% Analysis Alkaline Normal Adequate oxygen Alkaline Normal Normal

pH pCO2 pO2 HCO3 B.E(B) O2 Sat Interpretation: Uncompensated/ simple metabolic alkalosis with adequate oxygenation Date: January 23, 2013 Laboratory Exam Color Transparency WBC RBC Bacteria Epithelial Cells Cast Glucose pH Urinalysis Normal Values Result Light Yellow Clear to hazy 0-3/hpf 0-2/hpf 0-50 0-3/hpf 0-3 Negative 6.5-8.0 Light Yellow Hazy 1/hpf 2/hpf 1 0 0 Negative 7.0

Significance Normal Normal Normal Normal Normal Normal Normal Normal Normal

protein Specific Gravity

Negative 1.010-1.025

Negative 1.010

Normal Normal

Diagnostic Examination CT Scan

Result Acute Infarct, left frontoparietal lobes and lentiform nucleus 1. High resistant waveform pattern on left common carotid artery bulb and internal carotid artery with a low peak systolic velocity indicates a more distal lesion or stenosis 2. Irregular Doppler rhythm throughout the study 3. Suggest CTA/MRA of the carotid and vertebrobasilar system (R/O thromboembolism) Result Normal ECG pattern

January 23, 2013 Carotid Doppler Ultrasound

ECG January 20, 2013 H.R= 65/min (0.916s) PR= 0.202s QRS= 0.094s Axis= 15 degree QT/ QTC= 0.392s/ 0.408 sec RV5= 0.90mv SV1= 0.60 mv

Date: January 20, 2013 Nutritional Risk level: 0 = Low Risk Level (Level 1) 1-2 = Moderate Risk Lever (Level 2) 3 and above = High Risk Level (Level 3) BMI Category: Obese Class I Ht.: 56 BMI: 28.4 Wt.: 80 kg IBW: 62 A SGA Grade BMI TLC Total Score = 3 0 18.5 25 >1500 1 25.1 30 900 < 1500 B 2 <18.5 or >30 <900 C

VII. ANATOMY AND PHYSIOLOGY The nervous system consists of two major parts: the central nervous system (CNS), including the brain and spinal cord, and the peripheral nervous system, which includes the cranial nerves, spinal nerves and autonomic nervous system. The function of the nervous system is to control motor, sensory, autonomic,

cognitive, and behavioral activities. The brain itself contains more than 100 billion cells that link the motor and sensory pathways, monitor the bodys processes, respond to the internal and external environment, maintain homeostasis, and direct all psychological, biologic, physical activity thought complex chemical and electrical messages. Brain - is the center of the human nervous system and is a highly complex organ. The brain accounts for approximately 2% of the total body weight; in an average young adult, the brain weighs approximately 1400 g, whereas 1200 g. the brain is divided into three major areas: the cerebrum, the brain stem and the cerebellum. The cerebrum is composed of two hemispheres, the thalamus, the hypothalamus, and the basal ganglia. The brain stem includes the midbrain, pons, medulla oblongata. The cerebellum is located under the cerebrum and behind the brain stem. Cerebral hemispheres are: Frontal lobe is the largest lobe, located in the front of the brain. The major functions of this lobe are concentration, abstract thought, information storage or memory and motor function. It contains the Brocas area, which is located in the left hemisphere and is critical for motor control speech. The frontal lobe is also responsible in large part for a persons affect, judgment, person ality, and inhibitors. Parietal lobe a predominantly sensory lobe posterior to frontal lobe. This lobe analyzes sensory information and relays the interpretation of this information to other cortical areas and is essential to persons awareness of body p osition in space, size and shape discrimination, and right left orientation.

Temporal lobe

- located inferior to the frontal and parietal lobes, this lobe

contains the auditory receptive areas and plays a role in memory of sound and understanding of language and music. Occipital lobe located posterior to the parietal lobe, this lobe is responsible for visual interpretation and memory. The posterior part of the forebrain is the diancephalon, consisting of the hypothalamus, thalamus, metathalamus, and epithalamus; the subthalamus is often recognized as a distinct division. Thalamus is a large, dual lobed mass of grey matter buried under the cerebral cortex. It is involved in sensory perception and regulation of motor functions. Epithalamus the part of the diencephalon just superior and posterior to the thalamus, comprising the pineal body and adjacent structures and Pineal gland is a pine cone shaped gland, connects the endocrine system with the nervous system in that it converts nerve signals from the sympathetic system of the peripheral nervous system into hormone signals. The hypothalamus controls the autonomic nervous system and the secretion of hormones by the pituitary gland. Through these nerve and hormone channels, the hypothalamus regulates many vital biological processes, including body temperature, blood pressure, thirst, hunger, and the sleep-wake cycle.

Brainstem is the region of the brain that connects the cerebrum with the spinal cord. It consists of the midbrain, medulla oblongata, and the pons. Motor and sensory neurons travel through the brainstem allowing for the relay of signals between the brain and the spinal cord. The brainstem coordinates motor control signals sent from the brain to the body. The brainstem also controls life supporting autonomic functions of the peripheral nervous system.

Medulla oblongata, also called medulla, the lowest part of the brain and the lowest portion of the brainstem. The medulla oblongata is connected by the pons to the midbrain and is continuous posteriorly with the spinal cord, with which it merges at the opening (foramen magnum) at the base of the skull. The pons helps in the transferring of messages between various parts of the brain and the spinal cord. The midbrain is the smallest region of the brain that acts as a sort of relay station for auditory and visual information. The midbrain controls many important functions such as the visual and auditory systems as well as eye movement. Portions of the midbrain called the red nucleus and the substantia

nigra are involved in the control of body movement. The darkly pigmented substantia nigra contains a large number of dopamine-producing neurons are located. Cerebellum (little brain) is a structure that is located at the back of the brain, underlying the occipital and temporal lobes of the cerebral cortex. Although the cerebellum accounts for approximately 10% of the brains volume, it contains over 50% of the total number of neurons in the brain. It integrates sensory information to provide smooth coordinated movement. It controls fine movement, balance and position sense or proprioception. Sensory Function The CNS constantly receives large amounts of sensory input in response to a variety of stimuli originating both inside and outside of the body. The spinal cord and brainstem contain a number of ascending tracts or pathways that transmit action potentials from periphery to various parts of the brain. The motor system of the brain and spinal cord is responsible for maintaining the bodys posture and balance as well as moving the trunk, head, limb, tongue and eyes; and communicating through facial expressions and speech. The brain is divided into two hemispheres, called the left and right hemispheres. Each hemisphere provides a different set of functions, behaviors, and controls. The right hemisphere is often called the creative side of the brain, while the left hemisphere is the logical or analytical side of the brain. Cerebral Circulation: The brain does not store nutrients and requires a constant supply of oxygen. These needs are met through cerebral circulation; the brain receives approximately 15% of the cardiac output, or 750 ml per minute of blood flow. Brain circulation is unique in several aspects. First, arterial and venous circulation is not parallel as in other organs in the body; this is due in part to the role the venous system plays in CSF absorption. Second, the brain has collateral circulation through the circle of Willis, allowing blood flow to the redirected on demand. Third, blood vessels in the brain have two rather than three layers, which may make them more prone to rupture when weakened or under pressure. Arteries blood supply to the brain originates from the common carotid artery, the

first bifurcation off the aorta. The internal carotid arteries arise at the bifurcation of the common carotid and supply much of the anterior circulation of the brain. Branches of the internal carotid arteries, anterior and middle cerebral arteries, along with their connections, anterior and posterior communicating arteries, form the circle of Willis. The vertebral arteries branch from the subclavian arteries to supply most of the posterior circulation of the brain. At the level of the brain stem, the vertebral arteries join to form the basilar artery. The basilar artery divides to form the two branches of the posterior cerebral arteries. Functionally, the posterior portion of the circulation and the anterior or carotid circulation usually remain separate. However, the circle of Willis can provide collateral circulation if one of the vessels supplying it becomes occluded or its ligated. The bifurcations along the circle of Willis are frequent sites of aneurysm formation due to vessel wall weakness. Aneuryms can rupture and cause a hemorrhage stroke. 12 Cranial Nerves Number I II III IV V VI VII VIII IX Name Olfactory Optic Oculomotor Trochlear Trigeminal Abducens Facial General Functions Sensory Sensory Motor Motor Mixed Motor Mixed Specific Functions Smell Vision Muscles that move the eye and lid, Muscles that move the eye Facial sensation Muscles that move the eye Facial expression and muscle movement Hearing and equilibrium Taste, sensation in the pharynx and tongue. Muscles of the pharynx, parasympathetic innervation of thoracic and abdominal organs Sternocleidomastoid and trapezius muscle Movement of the tongue.

Acoustic Sensory Glossopharyngeal Mixed

Vagus

Mixed

XI XII

Accessory Hypoglossal

Motor Motor

VIII. PATHOPHYSIOLOGY CEREBROVASCULAR DISEASE


Non- modifiable factors Age-67 Genetics- History of HPN Gender- Male

Modifiable Factors Smoking Alcoholism Hypertension Obesity Diet- High Caloric, High Salt intake Hypertensive arteriosclerotic CVD

Sustained hypertension BP 140/90

Disruption of blood vessel lining

Exposure of underlying collagen

Platelet aggregates to initiate healing process

Permanent change in blood vessel architecture

Narrowing/stiffening of vessel walls

Decreased blood flow to brain

Ischemia

Infarct

CN III - No pupil reaction to light (left eye) CN III & IV - Impaired accommodation CN V - Analgesia (left side of face) No blink reflex (left eye) CN VII - Asymmetric facial facial features CN IX & XII - Unable to move tongue CN X - Dysphagia

CN X - Dysarthria Expressive aphasia CN XI - Unable to shrug shoulders (+) Babinski Dizziness Severe headache Cerebral contralateral paralysis

Hypertension embarks as the stem of cerebrovascular disease formation and exacerbation. Age and genetics are non-modifiable factors which have been linked to play a role in hypertension. Whereas non-modifiable factors such as smoking, obesity and diet, and alcoholism were theoretically believed to damage blood vessel lining thereby causing unusual changes in blood pressure. The later together with the additional modifiable factors such as hypertensive

atherosclerotic cerebrovascular disease and cardioembolism magnified the patients predisposition to cerebrovascular infarction. A person who has a history of smoking has a higher rate of acquiring cerebrovascular disease. Smoking has chemicals causing the disruption of blood vessel linings. High caloric diet as well, triggers the stiffening or inflexibility of the blood vessels which make them more susceptible to hypertension induced ischemia or infarction. The hardening and roughening of the vessel walls together with the presence of cardioemboli increases the possibility of tearing in sustained hypertension episodes. Likewise, the distortion from a normal endothelium may also occur in a manner that is thought to be beneficial for the body that is the healing process initiated by platelets and other clotting factors. During hypertension episodes, tearing of the endothelium is inevitable which exposes the underlying collagen. This event leads to the activation of the clotting factor and platelet aggregation to initiate restoration. However, the repairing process is not always complete and perfect. This permanently changes the architecture of the blood vessels making it narrow, stiff, uneven and more vulnerable to adhesions and further fluctuations in blood pressure. Due to narrowed blood vessel in the brain, embolus clogged and further resulted to poor blood circulation to the more distal portion of blood vessels. The sudden drop in blood pressure caused the antagonistic effect on the patient. In ischemia, blood flow to focal regions of the brain is impaired. Due to increased length of inadequate supply of oxygen to portions affected by the ischemia, infarction resulted.

IX. NURSING CARE PLAN DATE: JANUARY 28, 2013 Assessment Nursing Diagnosis Impaired physical mobility related to hemiparesis of the right side of the body Scientific Explanation Planning Intervention Independent Intervention: - Discussed the importance of mobility. - Taught regarding the possible risk for ulcerations and contractures. - Assisted the patient and the relatives in changing position to left side. - Put pillows on patients back, in between legs and below the bony prominences. - Advised relatives to change position slowly if possible

TIME: 10:00 AM Rationale Evaluation

Subjective: - Hindi na sya nakakagalaw sa higaan nya, as verbalized by the relative. Objective: - Inability to assume side lying or pronation. - Obesity with weight = 80kg -BMI: 28.4 - Motor strength =0/5 on right

A stroke is a condition in which the brain cells suddenly die because of a lack of oxygen. This can be caused by an obstruction in the blood flow, or the rupture of an artery that feeds the brain. The patient may suddenly lose the ability to speak, there may be memory problems, or one side of the body can become paralyzed. (www.medicalnewstoday. com)

Short Term : - After 1 hour of nursing intervention, the patient will be able to change position regularly with assistance of the relatives. Long Term: - After series of nursing interventions, the patient with the assistance of the family will be able to improve continuously physical mobility; and be free from ulcerations, contractures and pain.

Short term: - After 1 hour - Promotes of nursing understanding of intervention, repositioning. the patient was able to - Enhance the change understanding about position the risks of impaired regularly with physical mobility. assistance of the relatives. - To prevent Long Term: pressure ulcers. -After series of nursing interventions, the patient with the - Provides support to assistance of position and the family was prevents ulcers from able to developing. improve continuously physical - Promotes continuity mobility; and of care. be free from ulcerations,

or at least every 2 hours. - Demonstrated passive ROM to all limbs and joints. - Promotes circulation, muscle tone, joint flexibility, and prevents contractures and weakness. - To maintain joint mobility, regain motor control; prevent contractures in the paralyzed extremity.

contractures and pain.

-Encouraged the patient to exercise joints on left hemisphere and the relatives to perform passive and active ROM on the right hemisphere.

Interdependent Nursing Intervention: - Assist in physical therapy program (whenever ordered by the physician).

- Promotes problemfocused approach to healing.

DATE: January 28, 2013 Assessment Data Nursing Diagnosis Impaired Verbal Communication related to damage of CN IX, X and XII. Scientific Explanation Decreased, delayed, or absent ability to receive, process, transmit, and/or use a system of symbols may be caused by a decrease in circulation to brain and loss of facial/oral muscle tone/control; generalized weakness/fatigue Planning Intervention

TIME: 10:00 AM Rationale Expected Outcome

Subjective Data: Di naming maintindihan ang sinasabi ng pasyente as verbalized by the relatives. Objective Data: - Right facial paralysis - Muscle and facial tension - Speaks/verbalizes with difficulty; stuttering; slurring - Difficulty forming words or sentences - Absence of eye contact

Short Term: After 8 hours of nursing intervention, the patient will be able to establish a method of communication in which needs can be expressed. Long Term: After series of nursing interventions, the patient will be able to establish communication and relate to his environment progressively.

Independent Intervention: - Provided alternative methods of communication, like pictures, or visual cues, gestures and demonstration. - Talked directly to patient. Speaking slowly and directly. - Used yes or no question to begin.

After 8 hours of nursing - Provides intervention, communication of the patient was needs/ desires based able to on individual establish a situation/underlying method of deficit. communication through tapping of left index - Enhances clear and middle understanding and finger which decreases anxiety. corresponds to a yes and no - Reduces anxiety and answer confusion on having to respectively. respond with large amount of data. - Patient is not necessarily hearing impaired and raising voice may irritate or anger patient.

- Spoke in normal tones and avoid talking too much. Give patient ample time to respond.

- Encouraged family members and visitors to communicate with patient.

- To reduce patients isolation, promote establishment of effective communication, and maintain sense of connectedness with family. - Helpful in decreasing frustration when dependent on others.

- Anticipated and provide patients needs.

Interdependent Nursing Intervention: - Assist in speech therapy program (whenever ordered by the physician).

- Promotes problemfocused approach to healing.

DATE: JANUARY 28, 2013 Assessment Nursing Diagnosis Ineffective airway clearance related to ineffective cough and retained secretions. Scientific Explanation The inflammatory response to infection causes tissue edema and exudates formation in the lungs, the inflammatory response can narrow and potentially obstruct passages and alveoli Ref. MedicalSurgical Nursing Critical Thinking for Collaborative Care, col.1, 5th edition, Ignatius, et.al. page978 Planning Interventions Monitored vital signs especially the RR. Auscultated the lung sounds, noting areas of decreased ventilation and presence of adventitious sounds. Encouraged to increase fluid intake.

TIME: 10:00 AM Rationale Evaluation

Subjective: Medyo nahihirapan pa siyang huminga, as verbalized by the relative. Objective: Crackles heard Dyspnea Productive cough Vital signs: BPTPRRR-

After 4 hours of nursing interventions, the client will be able to maintain airway patency.

To obtain baseline data. Bronchial lung sounds are commonly heard over areas of lung density or consolidation. Hydration helps decrease the viscosity of secretions, facilitating expectorations. Positioning facilitates chest expansion and respiratory efficiency. Relaxes bronchial and uterine smooth muscle.

After 4 hours of nursing interventions, the client maintained airway patency as evidenced by expectorating clear secretions readily.

Advised the relatives to elevate the head of the bed at least 30 degrees. Assisted on nebulizer treatment.

X. DRUG STUDY
Classification and Mechanism of Action > Cardiac Glycosides >Inhibits sodiumpotassiumactivated adenosine triphosphatase, promoting movement of calcium from extracellular to intracellular cytoplasm and strengthening myocardial contraction. Also acts on CNS to enhance vagal tone, slowing conduction through the SA and AV nodes. Monitoring Parameters >Monitor vital signs (esp. pulse rate), potassium and digoxin level >May prolong PR interval or depress ST segment.

Name of drugs Generic Name: Digoxin Brand Name: Lanoxin Dose: 0. 25 mcg (1/2 tab) Route: oral Frequency: every other day

Indication >Atrial fibrillation and flutter

Contraindication >Hypersensitivity to drug and to those with digitalis-induced toxicity, ventricular fibrillation, or ventricular tachycardia unless caused by heart failure >Use with extreme caution in elderly patients and in those with acute MI, incomplete AV block, sinus bradycardia, PVCs, chronic constrictive pericarditis, hypertrophic cardiomyopathy, renal insufficiency, severe pulmonary disease, or hypothyroidism.

Side effects CNS: agitation, fatigue, generalized muscle weakness, hallucinations, dizziness, headache, malaise, paresthesia, stupor, vertigo. CV: arrthymias, heart block EENT: blurred vision, diplopia, light flashes, photophobia, yellow-green halos around visual images GI: anorexia, nausea, diarrhea, vomiting

Nursing Responsibilities >Before giving loading dose, obtain baseline data (heart rate, rhythm, blood pressure and electrolytes) and ask patient about use of cardiac glycosides within the previous 2-3 weeks. > Monitor digoxin level carefully. Take corrective action before hypokalemia occurs. Hyperkalemia may result from digoxin toxicity. > Excessively slow pulse rate may be a sign of digitalis toxicity. Withhold drug and notify prescriber. > Instruct patient to report adverse reactions promptly, nausea, vomiting, diarrhea, appetite loss, and visual disturbances these may be indicators of toxicity. >Encourage patient to eat a consistent amount of potassium-rich foods.

Classification and Name of drugs Mechanism of Action BRAND Antagonist NAME: aldosterone in Aldactone the distal GENERIC tubules, NAME: Spironolactone increasing sodium and DOSE: water excretion. Tablet 50mg FREQUENCY: Bid ROUTE: oral

Indication Management of essential hypertension, manangement of edematous conditions in CHF, treatment of hypokalemia,

Contraindication Acute renal insufficiency, anuria, hyperkalemia

Side effects Gynecomastia, agranulocytosis , headache, drowsiness, lethargy, GI disturbances, inability to achieve or maintain erection, irregular menses, amenorrhea, ataxia, postmenopausal bleeding, drug fever.

Nursing Responsibilities 1)Obtain patient history,including drug history and any known hypersensitivity 2)Assess fluid volume status:intake and outputratios and record,count or weigh diapers as appropriate,weight,di stended red veins, cracklesin lung,color,quality, and specific gravity of urine,skin turgor, adequacy of pulses,moist mucus membranes should be reported.

Monitoring Parameters 1)Monitor manifestations of hyperkalemia:MS:fatigue. muscle weakness;CV:arrythmias,hypoten sion,NEURO:paresthesias,confus ion,RESP:dyspnea 2)Monitor for manifestations of hyponatermia:CV:B\P,cold,clam my skin, hypo- or hypervolemia;GI:anorexia,nause a,vomiting,diarrhea,abdominal cramps:NEURO:lethargy, inceased ICP,confusion,headache,siezures ,coma,fatigue,tremor,hyperreflexi a. 3)Monitor for manifestations of hyperchloremia:NEURO:weakne ss,lethargy,coma;RESP:deep rapid breathing 4)Monitor electrolytes:potassium,sodium,ca lcium,magnesium;also include BUN,ABGs, uric acid, CBC,blood glucose.

Name of Drugs

Classification and Mechanism of Action Analgesics It may bind to mu- opioid receptors and inhibit reuptake of norepinephrin e and serotonin.

Indication

Side Effects

Contraindication

Nursing Responsibilities

Monitoring Parameters

Brand Name: Dolcet Generic Name: Tramadol Dose: 1 tab Freq: TID Route: PRN

Management of moderate to severe pain

CNS & GI disturbances: Nausea, dizziness, somnolence, asthenia, fatigue, hot flushes, constipation, diarrhea, flatulence, dry mouth, pruritus, increased sweating, tinnitus.

Acute intoxication w/ alcohol, hypnotics, narcotics, centrallyacting analgesics, opioids or psychotropic drugs. Hypersensitivity.

>Assess for location, onset and characteristics of pain. Use a pain- rating scale to rate pain. >Monitor vital signs and assess for orthostatic hypotension or signs of CNS depression. >Discontinue drug and notify the physician if signs and symptoms of hypersensitivity occur. >Assess bowel and bladder function, report urinary frequency or retention. >May be taken with or without food.

Monitor vital signs, I&O, liver and renal function studies.

Name of Drug Brand Name: Colchicine Generic Name: Colcrys Dose: 800 mg/ tab Freq:TID Route: oral

Classification and Mechanism of Action Antigout drug It may reduce the crystalinduced inflammation by reducing lactic acid production by leukocytes by inhibiting leukocyte migration and by reducing phagocytosis.

Indications

Side Effects

Contraindications

Nursing Responsibilities >Document joint involvement, noting pain, swelling and degree of mobility. >Take the medication on an empty stomach and it should be taken for at first sign of gout attack. >Teach client to report an increase or decrease in discomfort and swelling. >Instruct client to report nausea and vomiting or diarrhea.

Monitoring Responsibilities Monitor for alters liver function tests, increase alkaline phosphates, AST, decrease thrombocyte values and false positive for Hgb or RBC in urine

For the prophylaxis and the treatment of acute gout flares

CNS: Fatigue, headache, peripheral neuritis, sensory motor neuropathy Dermatologic: alopecia, macula papular rash, purpura, rash GI: Diarrhea, nausea, vomiting, abdominal cramping, abdominal pain, lactose intolerance

Serious GI, hepatic, cardiac, or renal disorders. Use in presence of combined renal and hepatic disease.

Name of Drug Brand Name: Zertin Generic name: Erdosteine Dose: 1cap Route: Oral Frequency: BID

Classification and Indication Mechanism of Action Classification: Treatment of Mucolytic Agents patients with acute and chronic Mechanism of bronchopulmonary Actions: diseases, Acts as a pro drug and rhinosinusitis, its metabolites are laryngopharyngitis mainly responsible for or exacerbations of mucolytic activity, due these chronic to the presence of free diseases in thiol groups which association with cause the splitting up mucus production of the intra- and and transport. intermolecular disulfide bridges of several proteins and mucoproteins present in the expectoration, resulting in a reduction of the mucus elasticity and viscosity.

Side effects GI side effects: Gastric burning, Nausea Diarrhea ageusia dysgeusia

Contraindications Hypersensitivity to erdosteine Hepatic disorders and abnormalities Renal insufficiency Homocystinuria Phenylketonuria

Nursing Responsibilities

Monitoring Parameters

Record the characteristics of cough and bronchial secretions before starting the therapy. Obtain and record baseline vital signs. Observe for and record any gastrointestina l symptoms before starting therapy.

Name of Drug

Classification

Indications

Contraindications

Side Effects

Nursing Considerations - Check cardiac rate before administration. - Take with or between meals. - Avoid grapefruit juice. - Skin test. - Take history of blood disorders and other related disorders.

Monitoring Parameters - Cardiac rate - GI discomfort - LOC - Inspect mouth regularly

Generic Name: Anticonvulsant Carbamazepine Mechanism of Action: Brand Name: - Carbamazepine Zynapse reduces polysynaptic responses and blocks Dose: 3ml post-tetanic Route: Oral potentiation. It is Freq: BID effective in partial and generalised convulsions as well as in mixed types but not in petit mal seizures. It reduces or abolishes pain in trigeminal and glossopharyngeal neuralgia.

Trigeminal and glossopharyngeal neuralgia, cerebrovascular diseases, in acute recovery phase, in signs & symptoms of cerebrovascular insufficiency & in cranial traumatism, epilepsy

Hypersensitivity, severe hemic disorders, severe bradycardia (<50beats/min), history of bone marrow depression, history of intermittent porphyria. (Pregnancy, lactation).

Dizziness, drowsiness, ataxia; dry mouth, abdominal pain, nausea, vomiting, anorexia; leucopenia, proteinuria, renal failure, heart failure and hyponatraemia. Potentially Fatal: Agranulocytosis, aplastic anaemia, hepatic failure, severe exfoliative dermatitis and StevensJohnson syndrome.

Name of Drug

Classification and Mechanism of Action Classification: Diuretic Mechanism of Actions: Increases the osmotic pressure of glomerular filtrate, which inhibits tubular reabsorption of water and electrolytes and increases urinary output.

Indication

Side effects

Contraindications

Nursing Responsibilities

Monitoring Paremeters

Brand Name: Osmotril Generic name: Mannitol Dose: 80cc Route: IV Frequency: Every 8 hours

Used for the promotion of diuresis before irreversible renal failure becomes established, the reduction of intracranial pressure, the treatment of cerebral edema, and the promotion of urinary excretion of toxic substances.

Dizziness Headache Rebound increased ICP Confusion Seizures Fever Dry Mouth

>Assess patients condition before Severe renal disease therapy and regularly thereafter Severe dehydration to monitor drug effectiveness. Pulmonary congestion >Assess neurologic status if drug is Severe pulmonary given for increased edema ICP:LOC,ICP reading ,pupil size and reaction. >Assess patient for tinnitus, hearing loss and ear pain. >Assess B/P before and during therapy w/ patient lying, standing and sitting, orthosthatic hypotension can occur rapidly. Hypersensitivity

Monitor a) Serum electrolytes, osmolality b) BUN, serum creatinine c) Urine output d) Central venous pressure, if possible e) Lung auscultation

Name of the Drug Generic Name: Omeprazole Brand Name: Omepron Dosage: 40 mg/cap Route: Oral Frequency: OD

Classification/ Mechanism of Action Antisecretory drug; Proton pump inhibitor Gastric acid-pump inhibitor: Suppresses gastric acid secretion by specific inhibition of the hydrogenpotassium ATPase enzyme system at the secretory surface of the gastricparietal cells; blocks the final step of acid production.

Indication

Contraindication

Adverse Reaction

Nursing Management

Monitoring Parameter Periodic Liver Function test.

Indicated for: Short-term treatment of activeduodenal ulcer;First-line therapy intreatment of heartburn orsymptoms of gastroesophageal refluxdisease (GERD); Short-term treatment of active benign gastric ulcer; GERD, severe erosiveesophagitis, poorlyresponsive symptomaticGERD; Long-term therapy:Treatment of pathologichypersecretory conditions(ZollingerEllisonsyndrome, multipleadenomas, systemicmastocytosis); Eradication of H. pyloriwith amoxicillin ormetronidazole andclarithromycin;

Contraindicated with hypersensitivity to omeprazole or its components; Use cautiously with pregnancy, lactation

Take the drug before meals. Report severe headache, worsening of symptoms, fever, chills. Swallow the Dermatologic:Rash, capsules whole; inflammation, do not chew, urticaria, pruritus, open, or crush alopecia, dry skin them. CNS: Headache, dizziness, asthenia, vertigo, insomnia, apathy, anxiety, paresthesias, dream abnormalities GI: Diarrhea, abdominal pain, nausea, vomiting, constipation, dry mouth, tongue atrophy Respirator: URTI symptoms, cough, epistaxis

Name of the Drug

Brand Name: Aprovel Generic Name: Irbesartan Dosage: 300mg Route: Oral Frequency: OD

Classification/ Mechanism of Action Antihypertensive Mechanism of Action: Inhibits the vasoconstricting and aldosteronesecreting effects of angiotensin II by selectively blocking binding of angiotensin Ii to receptor sites in many tissues. Therapeutic Effect: Lowers blood pressure.

Indication

Contraindication

Adverse Reaction

Nursing Management Monitor patients BP regularly. Monitor patients electrolytes. Assess patients and familys knowledge of drug therapy. Give with a diuretic if drug is needed to control blood pressure. Place in supine position and give an IV infusion of NSS if patient becomes hypotensive. Tell patient that drug may be taken once daily with or without food. Instruct client to avoid driving and hazardous activities until CNS effects of drug are known.

Monitoring Parameter Periodic liver and kidney function test.

For the treatment of hypertension & treatment of renal disease in patients with hypertension and type II diabetes mellitus, as part of an antihypertensive drug regimen.

Hypersensitivity to irbesartan.

CNS: fatigue, anxiety, dizziness, headache. CV: chest pain, edema, tachycardia. EENT: pharyngitis, rhinitis, sinus abnormality. GI: UTI. Metabolic: hyperkalemia. Musculoskeletal: musculoskeletal trauma or pain. Respiratory: URTI. Skin: rashes.

Drug Name

Classification and Mechanism of Action

Indication

Side Effects

Contraindications Nursing Responsibilities

Monitoring Parameters

Generic name: Levofloxacin ANTIBIOTICS

-infections caused by susceptible strains of microorganism

Brand name: Levox

Dosage: 500mg

-inhibits bacterial DNA gyrase and prevents DNA replication, transcription, repair and recombination in susceptible bacteria

-acute bacterial exacerbation

-CAP

Route: IV

-nosocomial pneumonia

Frequency: OD

CNS: seizures, encephalopathy, dizziness, headache, insomnia, pain CV: chest pain, palpitations, vasodilation GI: abdominal pain, nausea, constipation, diarrhea, vomiting RESPI: allergic pneumonitis, dyspnea MUSCULO: back pain, tendon rupture. SKIN: photosensitivity, pruritus, rash

With allergy to floroquinolones Use cautiously in patients with history of seizure disorder or CNS diseases

>If patient experiences symptoms of excessive CNS stimulation (restlessness, hallucinations, tremor, confusion) stop drug and notify prescriber. >Advise px to take the drug with plenty of fluids and to space antacids, sucralfate, and products containing iron and zinc. > Tell px to take oral soln 1 hour before or 2 hrs after eating >Advise px to avoid excessive sunlight, use sunscreen and wear protective clothing when outdoors. >Advice client to report sore throat, bruising, joint pain, furry tongue, loose stools or diarrhea

Assess renal function Assess bowel patterns Monitor glucose level May increase eosinophil count. May decrease WBC count.

Name Drug

of Classification Mechanism of action

and Indication

Side Effects

Contraindi cation

Nursing Responsiblities

Monitoring Parameters

>calcium channel blocker Brand Name: Norvasc Generic Name: Amlodipine Dose: 5mg Route: oral Freq: 1 tab Inhibits the movement of calcium ions across the membranes of cardiac and arterial muscle cells; inhibits transmembrane calcium flow, which results in the depression of impulse formation in specialized cardiac pacemaker cells, slowing of the velocity of conduction of the cardiac impulse, depression of myocardial contractility, and dilation of coronary arteries and arterioles and peripheral arterioles; these effects lead to decreased cardiac work, decreased cardiac oxygen consumption, and in patients with vasospastic (Prinzmetal's) angina, increased delivery of oxygen to cardiac cells.

Amlodipine is indicated for the treatment of hypertension, chronic stable angina and confirmed or suspected vasospastic angina.

CNS: dizziness; - dizziness or lightheadedness; - drowsiness; - excessive tiredness; - fainting; - fainting; - flushing (feeling of warmth); - headache; CV- more frequent or more severe chest pain; - rapid heartbeat; - rapid, pounding, or irregular heartbeat; GI- stomach pain; - upset stomach; SKIN- swelling of the hands, feet,

NORVASC is contraindicated in patients with known sensitivity to amlodipine.

Report significant swelling of face or extremities. Take care to have support when standing & walking due to possible doserelated lightheadedness/dizziness . Report shortness of breath, palpitations, irregular heartbeat, nausea, or constipation to physician. Can administer with or without food Caution patient to continue taking drug even when he feels better.

Monitor BP for therapeutic effectiveness. BP reduction is greatest after peak levels of amlodipine are achieved 69 h following oral doses. Monitor for S&S of doserelated peripheral or facial edema that may not be accompanied by weight gain; rarely, severe edema may cause discontinuatio

ankles, or lower legs;

n of drug. Monitor BP with postural changes. Report postural hypotension. Monitor more frequently when additional antihypertensi ves or diuretics are added. Monitor heart rate;

NAME OF DRUG

GENERIC NAME: Metoclopramide

BRAND NAME: Reglan

ROUTE: Oral FREQUENCY: q8o DOSAGE:1/2 tab, 5mg.

CLASSIFICATIO INDICATION ADVERSE N AND EFFECTS MECHANISM OF ACTION Prokinetic agent ( GI stimulant) To facilitate CNS:restlessness,dr intubation of owsiness,fatigue,inso small bowel; mia,dizziness,anxiety Blocks dopamine symptomatic receptors in treatment of CV:tansient chemoreceptor gastroesoph hypertension trigger zone of ageal reflux the CNS. GI:nausea and Stimulates diarrhea motility of the upper GI tract and accelerates gastric emptying

CONTRAINDICATION

NURSING RESPONSIBILITIE S

MONITORING PARAMETERS

Sensitivity or intolerance to metoclopramide; allergy to sulfiting agents; history of seizure disorders

>Report immediately the onset of restlessness, involuntary movements, facial grimacing, rigidity, or tremors. >Avoid alcohol and other CNS depressants. >Report S&S of acute dystonia, such as trembling hands and facial grimacing, immediately.

Monitor serum aldosterone it may be elevated Monitor the adverse reactions associated with increased serum prolactin concentration Monitor for possible hypernatremia and hypokalemia, especially if patient has CHF or cirrhosis.

NAME OF DRUG

CLASSIFICATION AND MECHANISM OF ACTION Laxative Lactulose promotes peristalsis by producing an osmotic effect in the colon with resultant distention. In hepatic encephalopathy, it reduces absorption of ammonium ions and toxic nitrogenous compounds, resulting in reduced blood ammonia concentrations it also Inhibits bacterial DNA gyrase thus preventing replication insusceptible bacteria.

INDICATION

ADVERSE EFFECTS

CONTRAINDICATION

NURSING MONITORING RESPONSIBILITIES PARAMETERS

GENERIC NAME: Lactulose

Use to treat constipation

BRAND NAME: Duphalac Route: oral Freq: OD Dose: 30mL

GI: Abdominal discomfort associated with flatulence and intestinal cramps, Nausea , vomiting and diarrhea

Contraindicated on patients with >low- galactose diet >diabetes mellitus

>Assess condition before therapy and reassess regularly thereafter, to monitor drug effectiveness >Monitor patient for any adverse GI reactions such as nausea, vomiting and diarrhea >Mix with fruit juice, water, or milk to make oral solution more palatable. >Instruct patient not to take other laxatives while receiving lactulose therapy

Monitor sodium level for hypernatremia Monitor potassium level

Name of Drug Generic Name: - Salbutamol Brand Name: - Duavent Dosage: 1-2 inhalation single dose. Frequency: q 8o Route: neb

Classification & Mechanism of Action - Adrenergic Inhalants/Bronchodilator - Stimulates beta 2 receptorsof bronchioles by increasing levels of cAMP which relaxes smooth muscles to produce bronchodilation.

Indication - Management of reversible bronchospasm associated with obstructive airway disease (eg. Bronchial asthma) ; COPD

Contraindication - Hypersensitivity to salbutamol also to atropine and its derivatives.

Adverse Effects Nursing Responsibilities - CNS: Fine - Give oral skeletal muscle administration with tremor, leg meals to decrease cramps, gastric irritation - CARDIO: - Instruct patient on palpitations, dosage and not to tachycardia, use more than hypertension, prescribed. headache, - Teach patient to hypotension, use inhaler peripheral - Instruct to limit vasodilatation, caffeine products flushing, feeling such as chocolates, of tension or coffee and tea. nervousness - Observe for - GI: nausea, paradoxical vomiting, bronchospasm dizziness, (Wheezing). hyperactivity If Condition occurs, with hold medication and notify physician or other healthcare professional immediately

Monitoring Parameters - Monitor vital signs especially heart rate

XI. PROGNOSIS Patient was admitted last January 20, 2013 with a chief complaint of difficulty waking up and a right sided body weakness. He underwent several laboratory and diagnostics examinations at Mary Mediatrics Medical Center such as Hematology, Blood Chemistry, Arterial Blood Gas and diagnostics such as Cranial Tomography Scan, and Carotid Doppler Studies for thorough verification and diagnosis of the disease. He had consistent Glasgow Coma Scale of 12 and he was given medication which includes Zertin, Mannitol, Approvel, Zynapse, Lactulose, Omeprazole, Approvel, Lanoxin, Lactulose, Amlodipine, Dolcet, Levofloxacin, and Combivent. Patient was discharged last February 2, 2013 and is currently undergoing physical therapy and speech therapy to support motor development and verbal communication. Care and safety measures were provided. In consideration to the management given together with the response of the patient to the therapeutic procedures, the patients prognosis is fair.

XII. DISCHARGE PLANNING / HEALTH TEACHING Encouraged the patient to promote a healthy lifestyle through maintaining a weight appropriate for height and age, following a healthy diet (including modest alcohol consumption) and daily exercise (about 3 to 5 times per week for 30 to 60 minutes. Advised the client to stay in a well-ventilated and quiet environment to minimize stress. Advised the client to manage stress. Do 20 minutes of relaxation per day. Advised the client to adhere to the treatment prescribed by the physician. Compliance is a must. Informed the patient for DASH diet (Dietary Approach to Stop Hypertension). The dash diet is high in fruits and vegetables, moderate in low fat dairy products and low in animal protein (has a substantial amount of plant protein from legumes and nuts) Advised the client to be patient because we all know that recovery from stroke takes time and patience. Encouraged the family to talk to the patient frequently to keep him from feeling sad and alone. Instructed the family to monitor blood pressure regularly, monitor blood sugar levels, and keep it in a healthy range and to prevent the accumulation of bad cholesterol. Advised the patient to immediately report the following symptoms/ and instructed the family to bring the patient to the nearest hospital as early as possible if these symptoms arise: 1. Weakness: Sudden weakness, numbness and/or tingling in the face, arm or leg 2. Visual problems: Sudden loss of vision, especially in one eye or double vision 3. Trouble Speaking: Temporary loss of speech, or trouble understanding speech 4. Headaches: Sudden, severe and unusual headaches 5. Dizziness: Sudden unsteadiness especially with any of the above signs Advised the client to attend mass every Sunday and have faith to our Creator. Instructed the family to help/ assist the client in performing activities of daily living. Return to OPD as advised by the physician

XIII. ACKNOWLEDGEMENT In completing this case study, the members of this group encountered many individuals who helped by offering their time, knowledge and skills. The group would like to give our deepest gratitude to these individuals

First and foremost to our creator Almighty God, for the gift of life and wisdom, for lending us time to do our task and for always giving us strength in completing this whole heartedly with such eagerness and passion.

To our parents, family and friends, for their unconditional love, for their emotional and financial support and for their endless understanding throughout the accomplishment of the presentation.

To the chief nurse and staff of Mary Mediatrix Medical Center who welcome us and assisted us throughout our stay in the hospital.

To our patient, for letting us know necessary information in completing our clinical appraisal and allowing the physical assessment to be done.

To our beloved clinical instructors, who have been patient and considerate in guiding us and sharing to us their knowledge and expertise in nursing, for understanding our shortcomings and our imperfections as a student and for the time they spent in providing us all the necessary knowledge we need to know.

XIV. REFERENCES Smeltzer S.C.,Bare B.G.,Hinkle J.L., Cheever K.H.(2010) Brunner and Suddarhts Texbook of Medical- Surgical Nursing. Twelfth Edition,18961931pp. Wolters Kluwer, Lippincott Williams & Wilkins. Blum, A. (1998) Role of Lymphocytes in Heart Disease Retrieved January 20, 2013 from http://www.circulationcirc.ahajournals.org Singh, V.N. (2013) Low HDL Cholesterol Hypoalphalipoproteneimia Retrieved January 21,2013 from emedicine.medscape.com/article/127943-overview Creatinine and Creatinine Clearance Retrieved from: http://www.webmd.com/a-to-z-guides/creatinine-and-creatinineclearance?page=3 Basophil Retrieved from: http://www.medfriendly.com/basophil.html Wedro, B.(2013) What causes heart murmur, Retrieved from: http://www.medicinenet.com/heart_murmur/page2.htm Salvador Cruz- Flores (2013) Physical Examination Retrieved from: http://emedicine.medscape.com/article/1916852-clinical#a0256 What do low creatinine levels mean? Retrieved from: http://www.netdoctor.co.uk/ate/liverandkidney/203123.html Larsen H. (2010) Importance of Potassium Retrieved from: http://afibbers.org/resources/potassium.pdf Balana Cynthia, (2010) Stroke afflicts the young, too, says expert Philippine Daily Inquirer from http://newsinfo.inquirer.net/inquirerheadlines/nation/view/20101020298702/Stroke-afflicts-the-young-too-says-expert