CALAYAN EDUCATIONAL FOUNDATION INC.

COLLEGE OF NURSING

A Nursing Case Study

CARDIOVASCULAR DISEASE

In the partial fulfillment of the requirements of the Related Learning Experience in General Ward

Submitted To:
Mrs. Wilma O. Rivadenera

Submitted By:
Ferry Geen G. Lagata
Angelica A. Luzentales
Eloisa R. Zulueta
Aniebee Montanio
Nikko Melenciom
Anonette Pereyra
Vernalyn Ortilano

OBJECTIVES
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After establishing a nurse-patient interaction, providing and rendering care to the client
such as by thorough assessment and careful study of the clients condition, student will gain
knowledge, develop skills, and enhance attitude through the utilization of the nursing process on
the care and management of the patient with pneumonia.
Specific Objectives
The student is expected to:
1. Define what CVA is.
2. Identify the different clinical manifestations.
3. Present the Anatomy and Physiology.
4. Trace the pathophysiology of the disease.
5. Establish a good and therapeutic nurse-patient interaction.
6. Determine the status of the patient through physical assessment.
7. Analyze laboratory results and correlate it with patients present condition.
8. Familiarize self with diagnostic procedures done to patient.
9. Render nursing care through implementation of Nursing Care Plan.
10. Evaluate the effectiveness of nursing care plan and medical management.

OVERVIEW OF THE DISEASE

PATIENTS PROFILE

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A.

GENERAL DATA
Name:
Age:
Sex:

Patient X
60 yrs. /old
Male

Civil Status:

Married

Address:
Occupation:
Nationality:
Religion:
Place of Birth:

Tum Baga I Sariaya Quezon

Not Applicable
Filipino
Iglesia Ni Christo
Sariaya Quezon

Date of Birth:

March 07, 1955

Case No:
Bed no.:
Admission Date:
Chief Complaint:
Admitting Diagnosis:

102304
ICU D
September 07,2015
T/C CVA

B. Physical Assessment
Parameters

Normal

Actual

Indication
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General appearance
Vital signs

Head
Hair

Eyes
Nose
Ears
Mouth
Neck

Chest

Abdomen
Bladder
Upper and Lower
Extremities
Nails
Skin

Conscious and coherent

Temperature= 37C
Pulse Rate= 60-100 bpm
Respiratory Rate= 20-40
cpm
Proportion to the body
Symmetrical
Black
Straight/ Wavy/ Curly hair
Evenly distributed
No lice present
Whitish sclera
Pinkish conjunctiva
Bilaterally patent
No nasal clogs noted
Symmetrical
Pinkish lips
Moist
No palpable mass
Symmetric at midline
position
With normal breath sounds
on both lung fields
With symmetrical chest
expansion
Soft and non-tender
With normal voiding
pattern
Can move freely
No lesions, deformities and
inflammation
Pinkish nail beds
Not brittle
Good skin turgor

Conscious and coherent

Temperature= 35.9C
Pulse Rate= 111 bpm
Respiratory Rate= 35 cpm

Normal
Afebrile

Proportion to the body

Symmetrical
Black
Straight hair
Evenly distributed hair
No lice present
Whitish sclera
Slightly pale conjunctiva
Bilaterally patent
No nasal clogs noted
Symmetrical
Pale lips
Slightly dry
No palpable mass
Symmetric at midline
position
With crackles sounds on
both lung fields
With symmetrical chest
expansion
Soft and non-tender
With normal voiding
pattern
Can move freely
No lesions, deformities

Normal

Bluish nail beds

Not brittle
Good skin turgor

Cyanosis

Slightly elevated

Not in distress

Normal

Normal
Normal
Normal
Slightly
cyanotic
Normal

Associated with
bronchitis,
pneumonia

Normal
Normal
Normal

Normal

Laboratory Results
09-07-15
CT SCAN
Impression: Normal Cranial CT Scan
09-09-15
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Impression: Acute Ischemic Infarction. Pariental, Bilateral

09-07-15
ECG
Impression: Inferior Wall Ischemic

Roentgenological Findings
Fibroid and hazy densites in the right upper lung, Calcified aortic knob, Heart is not enlarged,
Rest of chest structures unremarkable
Remarks: Minimal pulmonary tuberculosis (PTB) activity undetermined, Atheromatous aortic
knob
Complete Blood Count (CBC)
-15
Variable
Hemoglobin
Hematocrit
RBC

Result
12.3
37.60
3.81

WBC

8.88

MCV
MCH
MCHC
Neutrophils
Lymphocytes
Monocytes (%)
Eosinophils
Basophils
Platelet Count
RDW-CV

98.7
32.3
32.7
82.6
0.20
2.0
0.3
0.0
222
12.3

Variable
ProTime
Prothrombin
Control

Normal Value
12.0-15.5 grams/dL
34.9-44.5 percent
3.90-5.03 million
cells/mcL
3.5-10.5 billion
cells/L
80-100
26-34
31-36
55-65
25-35
1-10
1-5
1-5
150-450 billion/L
11.50-14.50

Hematology Report
08-23-15
Result
Normal Value
12.80sec.
11.2

Interpretation

Interpretation

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INR

1.14

Clinical Chemistry
Variable
Random Blood Sugar
Creatinine
Sodium
Potassium

Result

Normal Value

Interpretation

High

Clinical Chemistry

Variable
Uric Acid
Cholesterol
Triglycerides
Direct HDL
LDL
VLDL
C/H

Result

Normal Value
Conventiona
l
5.09mg/dl
120mg/dl
125mg/dl
37mg/dl
58mg/dl
25mg/dl
3.23

Low
Low

Interpretation

Reference
Values
3.5-8.5
139-201
0-150
40-60
0-130
7-32
0-5

Clinical Chemistry

Variable

Result

Normal Value

RBS 1:00PM

128

70-110

Interpretation

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ANATOMY AND PHYSIOLOGY OF THE RESPIRATORY SYSTEM

PATHOPHYSIOLOGY

COURSE IN THE WARD

Date

Doctors Order

September 7,
2015

Admit to ROC Under the

service of Dr. Salazar
Secure Consent for
admission and
management
TPR q shift
NPO temporarily

T-36.4
P-78
RR- 25

Nursing
Responsibility

Interpretation

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BP-110/80
O2 sat. 98%
RBS 121

9/7/15

9/8/15

1:15pm

9/9/15

PNSS 1Lx 16hrs.

Dx. Stroke panel, 12L
ECG, CXR PA, Plain
cranial CT Scan
Citicoline 1gm IVq8
V/S q10 + NVS
I/O q shift
Inform AP
Hook to O2 via NC @ 3
lpm
Refer Accordingly
Problem:Cerebral
Infarction, Right Distal
MCA, Cilostazol 50mg/
tab OD, PC SAP,
Zynapse 1g/ IVq8 hrs.,
Gelantin per orem with
SAP,
Problem 2: Macula
Papular Rashes, tunk,
upper thighs.
Levoceterizine 5mg/tab
OD start now with SAP.
For Lipid Profile, BUA
IVF to follow PNSS 1L*
10.
NPO temporarily,
monitor V/S + NVS q1 +
Record pls.
Telephone order revenue
for DR. Salazar by: insert
NGT, give OF 1200 kcal
in equal feeding.
Mannitol 20% 100 cc / IV
q6hrs.. Insert foly
catheter and drain to
urine bag. Clindamycin
300mg IV q8hrs.
Natravox 600mg IV
q8hrs.
Telephone order
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>12:30pm
update of
pt.s BP
100/90 (+)
Crackles
heard on
both lungs
fillds
ineffective
coughing out
of secreation.
>relayed CT
SCAN results

9/10/15

9/11/15

NTG patch 5mg once a

day. IVF to follow: PNSS
1Lx16hrs.
May give paracetamol
500mg/ tab, 1tab per
NGT q4 PRN for
T>37.8C. For
continuation of pt.
cranial CT SCAN (plain).
> Telephone order
suggest transfer to ICU
now, O2 @3 lpm with
furosemide 20mg/IV now.

>Telephone order
received from DR.
Salazar nebulize with
confivent 1 neb q8hrs.,
PNSS 1Lx16hrs.
>telephone order
received from DR.
Salazar final Diagnosis
for Abstract: Multiple
Cerebral Infarct Bilateral
Hemisphere .
PNSS 1Lx16hrs.
IVF to follow PNSS1L
x16hrs.
Cilostazol to 50mg/tab
1tab BID
D/C NTG patch
ISMN 30mg/tab 1tab OD
>D/C Levocitirizine
Turn side q2hrs.
Refer to DR. MT. Deleon
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for Rehab management .

PNSS 1Lx 16hrs.
Rehab Meds Notes:
Pt. seen and evaluated
Chart entries noted.
Will start on bed side
rehab.
Strict fall precautions.

NURSING CARE PLAN

DRUG STUDY
Therapeutic
Classification

Action

CITICOLINE
Contraindicatio
Toxicity/ Side
n
Effect

Interventio
n

Safe Dose

Page 10 of 12

Psycho
stimulant
and
Nootropics

Treatment of
cardiovascula
r disorders
including
(ischemic
stroke)
May increase
blood flows
and oxygen
consumption
in the brain in
the cause of
cerebro
vascular
disorders
therapy so
that it can be
disturbance of
consciousness.

Hypersensitivity
to citicoline
sodium or to any
of the excipient
of actimed
citicoline

Hypersensitivity
reaction:
Rash
Psychoneurologic :
Insomia, Headache,
Dizziness,
Convulsion
Gastrointestinal:
Nausea, Anorexia
Hepatic: Abnormal
Liver Function in
Laboratory
measurement
Eyes: Diplopia
Others: Flushing,
Transient Blood
Pressure changes or
Malaise.

Injury or
Brain
Surgery:
100500mg, 12 times
daily.
Psycholog
ic or
Neurologi
c
disorders
stage of
cerebral
infarction
: 500mg
once daily
for
consecuti
ve week
as
prescribe
d by the
physician.

DISCHARGE PLAN
M
E

T
H
O
D

Take paracetamol if temperature arises to 37.6C

Never stocked water in a container without cover, gallons containers tires must have proper
way of disposal, use mosquito repellants and mostly encourage the community to clean
surroundings to destroy the breeding places of mosquitoes.
Increase in oral fluid intake
Discuss the possible source of infection, educate the patient on how to eliminate those
vectors/ mosquitoes.
Encourage to eat nutritious foods such as meat, fruits and vegetables

PROGNOSIS
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With treatment, most types of bacterial pneumonia will stabilize in 3-6 days. It often
takes place a few weeks before most symptoms resolve. X-ray finding typically clear within four
weeks and mortality is low (less than1%), in the elderly or people with other lung problems,
recovery may take more than 12 and weeks. In persons requiring hospitalization, mortality may
be as high as 10% and in those requiring intensive care it may reach 30=-50%.

Bibliography
http://www.livescience.com/22616-respiratory-system.html

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