1

DIVINE WORD COLLEGE OF LAOAG

SCHOOL OF NURSING

LAOAG CITY

In Partial Fulfilment to the Requirements for N 15

Cardiovascular Disease

Submitted by:

Daizel Jade G. Tabios

BACHELOR OF SCIENCE IN NURSING IV – GROUP II

Submitted to:

Nemesio Daryl Boy G. Adora, III, RN, MAN

Carol U. Domingcil, RN, MAN

April 2, 2018
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I. BIOGRAPHIC DATA

 Name: Tata Ernest

 Address: Barangay Valdez, Banna, Ilocos Norte
 Gender: Male
 Age: 63 years old
 Birthdate: May 7 1954
 Place of Birth: Banna, Ilocos Norte
 Institution: Mariano Marcos Memorial Hospital and Medical Center
 Medical Record Number: 773770
 Marital Status: Married
 Religion: Roman Catholic
 Race or Ethnic Background: Filipino
 Educational Attainment: Elementary Level
 Occupation / source of income: Farmer
 Significant others or Support Persons: Mrs. Ancieta(Spouse)
Mrs. Lucile(Daughter)
 Admitting Diagnosis: CVD BLEED RIGHT BASAL GANGALIA HTN
UNCONTROLLED
 Date and Time of Admission: March 9, 2018 at 7:40 am
 Admitting Physician: Dra. Anna Dominique R. Sadian, M.D
 Final Diagnosis CVD BLEED RIGHT BASAL GANGALIA HTN
UNCONTROLLED

I. ANATOMY, PHYSIOLOGY, AND

PATHOPHYSIOLOGY

A. Anatomy and Physiology of the Nervous System

It is a network of nerve cells and nerve fibers that

are concerned with the reception of stimuli, the
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transmission of nerve impulses, or the activation of muscle mechanisms. The nervous system is
involved in some way in nearly every body function.

Major functions of Nervous System

1. Sensory Input. Sensory receptors monitor numerous external and internal stimuli that
may be interpreted as touch, temperature, taste, smell, sound, blood pressure, and body
position. Action potentials from the sensory receptors travel along nerves to the spinal
cord and brain, where they are interpreted.
2. Integration. The brain and spinal cord are the major organs for processing sensory input
and initiating responses. The input may produce an immediate response, may be stored as
memory, or may be ignored.
3. Homeostasis. The nervous system plays an important role in the maintenance of
homeostasis. This function depends on the ability of the nervous system to detect,
interpret, and respond to changes in internal and external conditions. In response, the
nervous system can stimulate or inhibit the activities of other systems to help maintain a
constant environment.
4. Mental activity. The brain is the center of mental activity, including consciousness,
memory, and thinking.
5. Control of muscles and glands. Skeletal muscles normally contract only when
stimulated by the nervous system. Thus, through the control of skeletal muscle, the
nervous system controls the major movements of the body. The nervous system also
participates in controlling cardiac muscle, smooth muscle, and many glands.

Division of Nervous System

A. Central Nervous System

A.1. Brain

A.2. Spinal Cord

The spinal cord is continuous with the medulla, extending from the
cerebral hemispheres and serving as the connection between the brain and the
periphery. Approximately 45 cm (18 inches) long and about the thickness of a
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finger, it extends from the foramen of magnum at the base of the skull to the
lower border of the first lumbar vertebra, where it tapers to a fibrous band called
the conusmedullaris. In cross-sectional view, it has an H-shaped central core of
nerve cell bodies (gray matter) surrounded by ascending and descending tracts
(white matter). Meninges surround the spinal cord.

B. Peripheral Nervous System

B.1. Cranial Nerves

Twelve pairs of cranial nerves emerge from the lower surface of the brain
and pass through openings in the base of the skull. Three are entirely sensory (I,
II, VIII), five are motor (III, IV, VI, XI, and XII), and four are mixed sensory and
motor (V, VII, IX, and X). The cranial nerves are numbered in the order in which
they arise from the brain. The cranial nerves innervate the head, neck, and
special sense structures.

B.2. Spinal Nerves

The spinal cord is composed of 31 pairs of spinal nerves: 8 cervical, 12

thoracic, 5 lumbar, 5 sacral, and 1 coccygeal. Each spinal nerve has a ventral root
and a dorsal root. The dorsal roots are sensory and transmit sensory impulses
from specific areas of the body known as dermatomes to the dorsal horn ganglia.
The sensory fiber may be somatic, carrying information about pain, temperature,
touch, and position sense (proprioception) from the tendons, joints, and body
surfaces; or visceral, carrying information from the internal organs.

The ventral roots are motor and transmit impulses from the spinal cord to
the body, and these fibers are also either somatic or visceral. The visceral fibers
include autonomic fibers that control the cardiac muscles and glandular
secretions.

B.3. Autonomic Nervous System

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The autonomic nervous system regulates the activities of internal organs

such as the heart, lungs, blood vessels, digestive organs, and glands. Maintenance
and restoration of internal homeostasis is largely the responsibility of the
autonomic nervous system. The autonomic nervous system innervates most body
organs. Although usually considered part of the peripheral nervous system, this
system is regulated by centers in the spinal cord, brain stem, and hypothalamus.

 2 Major Divisions of Autonomic Nervous System:

1. Sympathetic Nervous System
The sympathetic division of the autonomic nervous system
is best known for its role in the body’s “flight-or-flight” response
with predominantly excitatory responses. Under stress from either
physical or emotional causes, sympathetic impulses increase
greatly.
2. Parasympathetic Nervous System
The parasympathetic nervous system functions as the
dominant controller for most visceral effectors; the primary
neurotransmitter is acetylcholine. During quiet, nonstressful
conditions, impulses from parasympathetic fibers (cholinergic)
predominate.

Cells of the Nervous System

1. Neurons
It is the basic structural and functional unit of the nervous system.
 Basic Parts of a Neuron
a. Cell Body
It is also known as the perikaryon or soma which contains typical
cellular organelles such as nucleus, cytoplasm, lysosomes, mitochondria
and golgi apparatus.
b. Axon
It is a long, thin, cylindrical projection that conduct nerve impulse
away from the cell body and into another neuron, a muscle fiber or a
gland.
c. Dendrites
These are short highly branched process of a neuron which acts as
the receiving or input portion of a neuron.
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d. Other Parts:
i. Myelin Sheath
It is a multi-layered lipid and protein covering around some
axons that insulates them and increases the speed of nerve
impulse conduction.
ii. Node of Ranvier
Gaps in the myelin sheath where current flows easily
between extracellular fluid and the axon and action potentials can
develop.
iii. Axon Terminals
These are multiple fine processes branching from the tip of
an axon.
iv. Synaptic end bulbs
These are tips of an axon terminal which swell into bulb
like structures.
2. Neuroglia
It serves as adjuncts to the neuron which provides nourishment support and
protection.
 Types of Neuroglial Cell
a. Astrocytes
These are star-shaped cell which help maintain chemical
environment for conduction and transmission of impulses.
b. Oligodendrocytes
They produce the myelin sheath of axons in the central nervous
system.
c. Schwann cells
They produce the myelin sheath of axons in the peripheral nervous
system.
d. Microglia
These are small mobile cells in the central nervous system which is
a part of phagocytic process.
e. Ependymal cells
These are epithelial like cell which produce cerebrospinal fluid and
lines the ventricles of the brain.

Nerve Impulse Transmission

 Neurotransmitters
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They communicate messages from one neuron to another or from a neuron to a

specific target issue. Neurotransmitters are manufactured and stored in synaptic vesicles.
As an electrical action potential propagated along the axon reaches the nerve terminal,
neurotransmitters are released into the synapse. The neurotransmitter diffuses or is
transported across the synapse, binding to receptors in the postsynaptic cell membrane. A
neurotransmitter potential can either excite or inhibit activity of the target cell.
 Phases of an Action Potential
o Action Potential
It is a sequence of rapidly occurring events that decrease and reverse the
membrane potential and then eventually restoring it to resting phase.
1. Resting State
All voltage gated Na+ and K+ channels are closed. The inside of the cell is
negatively charged and the outside is positively charged. The cell is at resting
membrane potential (-70 mV). Resting membrane potential is the
transmembranevoltage that exist when a neuron is not producing an action
potential.

2. Depolarizing Phase
When the membrane potential of the cell reaches threshold (-55 mV), Na+
channels open. Depolarization occurs because of the influx of Na+ making the
inside of the cell more positive (+30 mV).
3. Repolarizing Phase
Na+ channels close and K+ channels are already open which causes a stop
in the movement of Na+ and movement of K+ inside the cell making inside the
cell negative again.
 Signal Transmission at the Synapse
1. When the nerve impulse arrives at the synaptic end bulb of presynaptic neuron, it
causes Ca+ channel gates to open.
2. Since Ca+ is more concentrated outside the cell, Ca+ moves into the cell.
3. The rapid influx of Ca+ will cause exocytosis of neurotransmitter contained in
synaptic vesicle to the synaptic cleft.
4. As neurotransmitters diffuse into the synaptic cleft, most of them bind with
neurotransmitter receptors located in ion channels at the postsynaptic neuron.
5. The binding of neurotransmitter with its receptor will cause the opening of ion
channels.

Anatomy and Physiology of the Brain

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The Brain

The brain accounts for approximately

2% of the total body weight; in an average
young adult, the brain weighs approximately
1400 g, whereas in an average elderly
person, the brain weighs approximately 1200
g. It consumes 20% of the oxygen supply of
the body and receives 15-20% of the cardiac
output. It also utilizes 65-70% of the glucose
supply of the body.

Major Areas of the Brain

1. Cerebrum
It is the largest and uppermost portion of the brain. The cerebrum consists of the
cerebral hemispheres and accounts for two-thirds of the total weight of the brain.
 Lobes of the cerebral hemisphere
a. Frontal
It 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 Broca’s area,
which is located in the left hemisphere and is critical for motor control
of speech. The frontal lobe is also responsible in largepart for a person’s
affect, judgment, personality, and inhibitions.
b. Parietal
It is a predominantly sensory lobe posterior to the frontal lobe.
This lobe analyzes sensory information and relays the interpretation of
this information to other cortical areas and is essential to a person’s
awareness of body position in space, size and shape discrimination, and
right-left orientation.
c. Temporal
It is 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.
d. Occipital
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It is located posterior to the parietal lobe, this lobe is responsible

for visual interpretation and memory.
 Coverings/Meninges
a. Dura Mater
The outermost layer; covers the brain and the spinal cord. It is
tough, thick, inelastic, fibrous, and gray. It consist of two layers of dense
fibrous tissue containing many blood vessels. The outer layer takes the
place of periosteum on the inner surface of the skull and the inner layer
covers the bone and spinal cord. A potential space between the skull and
dura mater may develop and this is known as epidural space. The two
layers are closely adherent except where the inner layer swept inward
between deep parts of the brain.
b. Arachnoid
The middle membrane; an extremely thin, delicate membrane that
closely resembles a spider web between the dura and pia mater. It is
separated from the dura mater by a potential space known as subdural
space. It is separated from pia mater by a definite space known as
subarachnoid space where cerebrospinal fluid flows.
c. Pia Mater
The innermost, thin, transparent layer that hugs the brain closely
and extends into every fold of the brain’s surface. It is a fine vascular
membrane consisting mainly of minute blood vessels supported by fine
connective tissue. It is closely adherent to the brain and spinal cord
completely covering their convolutions and dippings.
 Blood Supply to the Brain
 Circle of Willis
It is an interconnection of major arteries supplying the brain
that ensures equal
circulation of both
sides of the brain and helps compensate for
alterations in blood
flow and blood
pressure.
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The circle of Willis is formed when the internal carotid artery

(ICA) enters the cranial cavity bilaterally and divides into the anterior
cerebral artery (ACA) and middle cerebral artery (MCA). The anterior
cerebral arteries are then united by an anterior communicating (ACOM)
artery. These connections form the anterior half (anterior circulation) of
the circle of Willis. Posteriorly, the basilar artery, formed by the left and
right vertebral arteries, branches into a left and right posterior cerebral
artery (PCA), forming the posterior circulation. The PCAs complete the
circle of Willis by joining the internal carotid system anteriorly via the
posterior communicating (PCOM) arteries.
 There are five (5) Major Brain Arteries:
a. Anterior Cerebral Artery
The anterior cerebral artery supplies the parasagittal
cerebral cortex, which includes portions of motor and sensory
cortex related to the contralateral leg and the so-called bladder
inhibitory or micturation center. Supplies the anterior two- thirds of
the medial surface and adjacent region over the convexity of the
hemisphere, thus including about one-half of the parietal and
frontal lobes.
b. Middle Cerebral Artery
The middle cerebral artery supplies most of the remainder
of the cerebral hemisphere and deep subcortical structures. The
cortical branches of the middle cerebral artery include the superior
division, which supplies the entire motor and sensory cortical
representation of the face, hand and arm, and expressive language
or broca’s area of the dominant hemisphere. The inferior division
supplies the visual radiations, the region of visual cortex related to
macular vision, and the receptive language (Wernicke’s Area) of
the dominant hemisphere. Lenticulostriate branches of the most
proximal portion (stem) of the middle cerebral artery supply the
basal ganglia as well as motor fibers related to the face, hand, arm
and leg as they descend in the genu and the posterior limb of the
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internal capsule. Supplies one-half of the frontal, parietal and

temporal lobe.
c. Internal Carotid Artery
The internal carotid artery arises where the common carotid
artery divides into internal and external carotid branches in the
neck period. The internal carotid artery also gives rise to the
ophthalmic artery, which supplies the retina. The severity of
internal carotid artery strokes is highly variable, depending on the
adequacy of collateral circulation, which tends to develop
incompensation for slowly evolving occlusion.
d. Posterior Cerebral Artery
The paired posterior cerebral arteries arise from the tip of
the basilar artery and supply the occipital cerebral cortex, medial
temporal lobes, thalamus, and rostral midbrain. Emboli carried up
the basilar artery tend to lodge at its apex, where they can occlude
one or both posterior break up and produce signs of asymmetric or
patchy posterior cerebral artery infarction. Supplies the occipital
lobe and the remaining ½ of the temporal lobe.
e. Basilar Artery
The basilar artery usually arises from the junction of the
paired vertebral arteries, though in some cases only a single
vertebral artery is present. The basilar artery courses over the
ventral surface of the brain stem to terminate at the level of the
midbrain, where it bifurcates to from the posterior cerebral arteries.
Branches of the basilar artery supply the occipital and medial
temporal lobes, the medial thalamus, the posterior limb of the
internal capsule and the entire brainstem and cerebellar.
2. Brain Stem
a. Midbrain
It connects the pons and the cerebellum with the cerebral hemispheres; it
contains sensory and motor pathways and serves as the center for auditory and
visual reflexes. Cranial nerves III and IV originate in the midbrain.
b. Pons
It is situated in front of the cerebellum between the midbrain and the
medulla and is a bridge between the two halves of the cerebellum, and between
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the medulla and the midbrain. Cranial nerves V through VIII originate in the pons.
The pons also contains motor and sensory pathways. Portions of the pons help
regulate respiration.

c. Medulla Oblongata
Motor fibers from the brain to the spinal cord and sensory fibers from the
spinal cord to the brain are located in the medulla. Most of these fibers cross, or
decussate, at this level. Cranial nerves IX through XII originate in the medulla.
Reflex centers for respiration, blood pressure, heart rate, coughing, vomiting,
swallowing, and sneezing are located in the medulla as well. The reticular
formation, responsible for arousal and the sleep-wake cycle, begins in the medulla
and connects with numerous higher structures.
3. Cerebellum
The cerebellum is posterior to the midbrain and pons, and below the occipital
lobe. The cerebellum integrates sensory information to provide smooth coordinated
movement. It controls fine movement, balance, and position (postural) sense or
proprioception (awareness of where each part of the body is).
4. Diancephalon
a. Epithalamus
It is the most superior portion of the diencephalon. It consists of the pineal
body which secretes melatonin which contributes to the body’s biological clock,
onset of puberty and sleep and wake cycle.Habernular nuclei, on the other hand,
are involved in olfaction especially emotional responses to odor.
b. Thalamus
It relay almost all sensory input to the cerebral cortex. It also contributes
to motor function by transmitting information from the cerebellum and basal
ganglia to the primary motor area of cerebellum. It also relays nerve impulses
between different areas of the cerebrum and plays a role in the maintenance of
consciousness.
c. Hypothalamus
It controls and integrates activities of the autonomic nervous system. It
produces and releases various hormones. It also regulates emotional and
behavioral patterns. The hypothalamus contains feeding and satiety center
(regulates eating) and thirst center (regulates drinking). It also controls body
temperature.
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Limbic System
It lies just inferior to the cerebral cortex and contains neural pathways that
connect portions of the cerebral cortex and temporal lobes with the thalamus and the
hypothalamus. Functions involve olfaction, memory and emotion.
5. BASAL GANGALIA

The basal gangalia is form a fundamental component of the vertebrates

telencephalon (forebrain) in contrast to the pallial or cortical layer that lines the surface of the
forebrain, the basal gangalia a collection of distinct masses of gray matter lying in the interior
not far from the junction with the thalamus. Like most parts of the brain, the basal ganglia
consist of left and right sides are virtual mirror images of each other.

At the highest level, the basal gangalia are divided by anatomist o four distinct
structures. Two of them the striatum and palladium are relatively large; the other two, the
substania nigra and subthalamic nucleus, are smaller In the illustration to the right coronal
selections of the human brain show the location of the basal gangalia. The subthalamic nucleues
and substania nigra lie further back the brain that striatum and palladium.

Connections:

The flow of neural signals through the basal gangalia is strongly directional. The strongly
directional. The striatrum is the primary receipt of the input from other brain areas, most notably
the cerebral cortex. The internal segment of the globus pallidus (GPe), together with the reticular
part of the substania nigra (SNr), give rise to primary output, most notably to the thalamus. The
striatum projects to the pallidium both directly and indirectly via the subthalamic nucleus, which
also receives cortical input. The functions similarly to the palladium, the other of functions
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similarly to the palladium, the other of which sends a modulatory dopaminergic input to the
striatum and other structures.

The adjoining figure shows some of the most important connections between
components. On the largest sacle. The basal gangalia form a loop that begins and ends in the
cortex. Anatomist have distinguished two main circuits as the “direct” and “indirect” pathways.
The direct pathway runs cortex striatum GPi thalamus cortex. Two of these links are
excitory, and two inhibitory, so the net effect of the whole sequence is excitory: the cortex
excites itself via the direct pathway. The indirect pathway runs cortex striatum GPe STN
GPi thalamus cortex. Three of these links are inhibitory and two excitory, so the net effect
of sequence is inhibitory the cortex inhibits itself via the indirect pathway. The total effect of
basal gangalia upon the cortex is believed to result from a complex between the two pathways

Striatum

The striatum is the largest component of basal gangalia. The term “striatum” comes the
observation that this structures has a striped appearance when sliced in certain directions. Arising
from numerous large and small bundles of nerve fibers (white matter) that transverse it. Early
anatomist, examining the human brain, perceived the striatum as two distinct masses of gray
matter seperates by a large tract of the white matter called the internal capsule. They named these
two masses the “caudate nucleus” and “putamen”. More recent anatomist have concluded, on the
basis of microscopic and neurochemical studies, that is more appropriate to consider these
masses as two separated parts of a single entity the “striatum” in the same way that a city may
be separated into two parts by a river. Numerous functional differences between the caudate and
putamen have been identified. But these are taken to be consequences of the fact that each sector
of the striatum is prefentially connected to specific parts of he cerebral cortex.

Pallidum

The pallidum consist of a large structure called the globus pallidus(“pale globe”) together
with a smaller ventral extension called the ventral pallidum. The globus pallidus appears as a
single neural mass, but can be divided into two functionally distinct parts, called the intenal
(sometimes “medial”) and external (sometimes “lateral”) segments, abbreviated GPi and GPe,
Both segments contains primarily GABAergic neurons, which therefore have inhibitory effects
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on their targts. The two segments participate in distinct nueral circuits. The external segment or
GPe receives input mainly from striatum and projects to the subthalmic nucleuis. The internal
segment or GPi , receives signals from the striatum via two pathways, called “direct” and
“indirect”. The direct pathway consists of direct projections from the striatum to the GPi. The
indirect pathway consist of projections from the striatum to the GPe, followed by projections
from the GPe, to the Subthalmic nucleus (STN), followed by projections from the STN to the
GPi. These pathways have opposite net effects: striatal activity inhibits the GPi via direct
pathways beacause striatal outputs are GABAergic, but has net excitory effect on the Gpi via the
indirect link plus one excitory link.

Pallidal neurons operate using “dishibition” principle. These neurons fire at steady high
rates in the absence of input and signals from the striatum cause them to “pause” Because
pallidal neurons themselves have inhibitory effects on their targets, the net effect of striatal input
to the palladium is reduction of the tonci inhibition exerted by pallidal cells on tagets.

Subthalamic nucleus

Function

The greatest source of insight into the functions of the basal gangalia has come from the
study of two neurological disorders Parkinson’s disease and Huntington’s disease. For both of
these disorders. The nature of nueral damage is well understood and can be correlated with
resulting symptoms. Parkinson’s disease involves major loss of dopaminergic cells in the
substania nigra ;Huntington’s disease involves massive loss of medium spiny neurons in the
striatum. The symptoms of two diseases are virtually opposite Parkinson’s disease is
characterized by gradual loss of the ability to initiate movement while Huntington’s disease is
characterized by an inability to prevent parts of the body from moving unintentionally. It is

B. Readings

Pathophysiology of Cerebrovascular DiseaseDefinition of Cerebrovascular Disease

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Cerebrovascular disorder is an umbrella term that refers to a functional abnormality of

the central nervous system that occurs when the normal blood supply to the brain is disrupted.
Cerebrovascular disease is the most frequently occurring neurologic disorder, accounting for
more than 50% of the persons admitted to general hospitals with neurologic problems. Any
abnormality of the brain caused by a pathologic process in the blood vessels is referred to as a
cerebrovascular disease. Included in this category are lesions of the vessel wall, occlusion of the
vessel lumen by thrombus or embolus, rupture of the vessel, and alteration in blood quality such
as increased blood viscosity.

Cerebrovascular disease is also known as stroke, acute brain infarction, apoplexy and
brain attack. The term, brain attack, being used to suggest health care practitioners and the public
that a stroke is an urgent health care issue similar to heart attack.

Major Categories of Stroke

1. Ischemic Stroke
It is a type of cerebrovascular disease caused by deprivation of blood flow to an
area of the brain which is generally caused by embolism, thrombosis or reduced blood
pressure. It accounts 80% of all types of stroke.
 Types of Ischemic Stroke
a. Thrombotic Stroke
Thrombotic strokes (cerebral thromboses) occur when arteries
supplying the brain or the intracranial vessels are occluded by thrombi
that arise from arterial occlusions. Cerebral thrombosis develops most
frequently with atherosclerosis and inflammatory disease process
(arteritis) that damage arterial walls. Onset of manifestations is gradual
because occlusion is also gradual. Patients may have experienced stroke-
like symptoms weeks before the stroke. It occurs among clients with
diabetes mellitus and hypertension. Transient ischemic attack may be a
warning sign.
 Subdivisions of Thrombotic Stroke
i. Transient Ischemic Attack (TIA)
It is a warning sign or impending stroke and
localized ischemic event that produces temporary
neurologic deficit which evolves within minutes to hours or
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up to 24 hours. Syndrome of brief and temporary episodes

of neurologic deficits that pass without apparent residual
effects.
ii. Reversible Ischemic Neurologic Deficit (RIND)
It is a period of persistent ischemia without actual
infarction or submaximal infarction lasting for more than
24 hours. It is also characterized by reversible neurologic
deficit.
iii. Stroke in Evolution / Progressive Stroke
An intermittent progression of a neurologic deficit
over hours to days characteristic of thrombotic stroke or
slow hemorrhage.
iv. Completed Stroke
It is a cerebrovascular accident that has reached its
maximum destructiveness in producing neurologic deficits,
although cerebral edema may not have reached its
maximum.
b. Embolic Stroke
An embolic stroke involves fragments that break from a thrombus
formed outside the brain, in the heart, aorta, or common carotid. Emboli
infrequently arise from the ascending aorta or common carotid artery.
The embolus usually involves small brain vessels and obstructs at a
bifurcation or other point of narrowing, thus causing ischemia. An
embolus may plug the lumen entirely and remain in place or break into
fragments and move up the vessel. Onset of manifestations is sudden
and unrelated to activity. Sometimes appear without warning signs.
2. Hemorrhagic Stroke
Hemorrhagic stroke (intracranial hemorrhage) is the third most frequent cause of
cerebrovascular accident. Hypertension, ruptured aneurysms or arteriovenous
malformation, bleeding into a tumor, and hemorrhage associated with bleeding disorders
are common causes. It is less common than ischemic stroke and has higher mortality rate.
Onset is abrupt, typically occurs during waking hours and commonly occurs suddenly
while a person is physically active.

Risk Factors for CVD

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 Non-modifiable
1. Age
The incidence of ischemic stroke increases with age starting 55 years old.
However, the incidence of hemorrhagic stroke is higher in young adults.
2. Sex
The overall incidence of stroke is higher in men than in women. Although
incidence increases after menopause. Stroke incidence rates are 1.25 times greater
in men, but because women tend to live longer than men, more women than men
die of stroke each year.
3. Race
The overall incidence of CVA among African American is twice that of
whites with greater morbidity and mortality. The high incidence among African
American is related to this. There are no clear reasons why African Americans
have an increased risk of stroke.
4. Heredity
The human NOTCH3 gene on chromosome encodes the human Notch3
receptor, a 2321 amino acid type I transmembrane protein that forms part of the
notch intercellular communication system. This system is thought to be involved
in controlling cell fate during development and has important roles in arterial
development with the Notch3 receptor being expressed on vascular smooth
muscle cells. Cerebral autosomal dominant arteriopathy with subcortical infarcts
and leucoencephalopathy (CADASIL) is caused by mutations of the human
NOTCH3 gene; the majority are missense mutations involving cysteine residues,
90% of which involve exons. CADASIL is an inherited condition that causes
stroke and other impairments. This condition damagesblood vessel walls in the
brain, thereby blocking blood flow in small blood vessels, particularly cerebral
vessels within the brain.
Another factor that increases the risk of heredity to stroke is the familial
tendency with diseases such as hypertension and diabetes mellitus.
5. Personal History of Stroke
The risk of stroke for someone who has already had one is many times that
of a person who has not. Transient ischemic attacks (TIAs) are "warning strokes"
that produce stroke-like symptoms but no lasting damage. TIAs are strong
predictors of stroke. A person who had one or more TIAs is almost 10 times more
likely to have a stroke than someone of the same age and sex who has not.
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Recognizing and treating TIAs can reduce your risk of a major stroke. TIA should
be considered a medical emergency and followed up immediately with a
healthcare professional.
 Partially Modifiable
1. Hypertension
Uncontrolled high blood pressure increases a person's stroke risk by four
to six times. When the heart beats, it pushes blood through the arteries in the
entire body. Higher blood pressures mean that with each beat, arteries throughout
the body swell and stretch more than they would normally. This stretching can
injure the endothelium, the delicate lining of all arteries.
Healthy endothelium actively works to prevent atherosclerosis, also called
hardening of the arteries, from developing. Injured endothelium, on the other
hand, attracts more "bad" LDL cholesterol and white blood cells. The cholesterol
and cells build up in the artery wall, eventually forming the plaque of
atherosclerosis.
Plaque is dangerous. Although it often grows without symptoms for years,
plaque can suddenly rupture, forming a blood clot that blocks the artery. The
result can be a heart attack or stroke.Over time, hypertension leads to
atherosclerosis and hardening of the large arteries. This, in turn, can lead to
blockage of small blood vessels in the brain. Degenerative changes from
hypertension can also lead to weakening of the blood vessels in the brain, causing
rupture of the blood vessel. The risk of stroke is directly related to how high the
blood pressure is.
2. Diabetes Mellitus
Hyperglycemia damages blood vessels through a process called
“atherosclerosis”, or clogging of arteries. This narrowing of arteries can lead to
decreased blood flow to heart muscle (causing a heart attack), or to brain (leading
to stroke). Normal blood vessels have an inner lining, called endothelium, that
keeps blood flowing smoothly by producing local Nitrous oxide (NO). NO serves
to relax the smooth muscles in the walls of the vessels and prevent cells from
sticking to the walls. A disruption of this mechanism is thought to be at the heart
of the increased formation of plaques in diabetes. High blood sugar, elevated fatty
acids and triglycerides leads to stickier walls, encouraging the attachment of cells
 20

that produce local tissue reaction. The local tissue reaction further traps floating
particles and different blood cells, heaping up and hardening the vessel walls.
Insulin stimulates the production of NO by the cells lining the blood
vessels. In diabetics who are resistant to the actions of insulin, this stimulatory
effect is lost, resulting in increased tendencies towards plaque formation.
In the presence of raised blood sugar and resistance to insulin, the lining
cells of the blood vessels not only reduce production of NO, they also increase the
production of substances that constrict the blood vessel, further encouraging
plaque formation. The smooth muscles of the blood vessels are also hyperactive in
diabetes.
Platelets and clotting factors are also affected by the high blood sugar,
fatty acids and free radicals in diabetes. The blood cells are much stickier and the
factors that inhibit clots do not work well under the peculiar circumstances of
diabetes.
3. Cardiac Impairments
Stroke also develop from emboli originating from the heart and can move
into and block cerebral arteries. This include the following: atrial fibrillation,
myocardial infarction, valvular disease and congestive heart disease.
4. Blood lipid abnormalities
"Bad" cholesterol, also called low-density lipoprotein (LDL), has chemical
properties that can damage arteries. Damaged areas allow more LDL to penetrate
artery walls. The LDL gets stuck and accumulates in the artery's wall.
Inside the artery wall, free radicals transform LDL from something bad to
something worse: oxidized LDL. The oxidation of LDL occurs when the LDL
cholesterol particles in the body react with free radicals.
Once LDL becomes oxidized, it goes directly within the inner-lining
(endothelium) of any artery in the body, including the carotid artery, coronary
artery or the arteries that supply the legs and arms with blood. Once there, it
encourages the accumulation of inflammatory cells, such as macrophages, and
platelets at the site of the vessel and promotes their adhesion to the damaged area.
More macrophages, cholesterol and other lipids begin to accumulate at the site,
forming a plaque that begins to grow thicker. Over time, this can slowor
completely restrict the amount of blood flow that travels to one or more areas of
the body especially to the brain which could possibly lead to stroke.
 21

On the other hand, high triglyceride levels may indicate the presence of fat
particles similar to "bad" low-density lipoprotein (LDL) cholesterol, which can
also contribute to the build-up of plaque in arterial walls.
 Modifiable
1. Smoking
Smoking doubles the risk for stroke when compared to a nonsmoker.
Nicotine is probably not a carcinogen, but it has other deleterious effects. It acts
by stimulating the sympathetic nervous system, resulting in increased heart rate,
increased peripheral vasoconstriction, increased BP, and increased cardiac
overload. Nicotine also decreases the amount of functional hemoglobin and
increases platelet aggregation. These effects of nicotine compound the problem in
a person with coronary artery disease.Blood clots become more likely because of
the nicotine.Smoking also increases the amount of build-up in the arteries, which
may block the flow of blood to the brain, causing a stroke.
Carbon monoxide (CO) is a component of tobacco smoke. CO has high
affinity for hemoglobin and combines with it more readily than does oxygen,
causing formation of carboxyhemoglobin thereby reducing the smoker’s oxygen-
carrying capacity. The heart’s need for oxygen is increased because of the
stimulatory effect of nicotine on the sympathetic nervous system. Because the
blood’s oxygen-carrying capacity is reduced, the heart must pump more rapidly to
adequately supply tissues with oxygen and allowing blood clots to form more
easily.The carbon monoxide from smoking cigarettes causes cholesterol deposits
to form on the arterial walls. The combination of high blood pressure and high
cholesterol can cause a stroke.
2. Obesity
The increased risk of obesity in the occurrence of stroke is associated to
hypertension and hyperlipidemia.
3. Stress
The sympathetic nervous system is aroused during the stress response and
causes the medulla of the adrenal gland to release catecholamines (ephinephrine,
norepinephrine, dopamine) into the bloodstream. The release of catecholamine
during stress response increase platelet aggregation which increases the likelihood
of thrombus formation.
4. Diet
 22

High fat diet is associated to hypertension and the development of

atherosclerosis.

General Manifestations of CVD

1. Premonitory manifestations
 Persistent headache
 Slurring of speech
 Blurring of vision
 Lightheadedness
 Thickening of the tongue
 Numbness/weakness of a body part
2. Vital signs
 Slow bounding pulse
 Cushing’s triad
 Chyne-stokes respiration with periods of apnea
3. Motor Deficits
 Hemiplegia –paralysis of one side of the body
 Hemiparesis – muscular weakness of one half of the body
 Flaccidity – lack of muscle tone
 Spasticity – increased muscle tone
 Ataxia – an impaired ability to coordinate movement
 Dysarthria – poorly articulated speech, resulting from interference in the
control and execution over the muscles of speech
 Dysphagia – difficulty of swallowing
4. Sensory deficits
 Loss of sensation
 Diminished response to superficial sensation
 Paresthesia– a sensation of numbness, prickling or tingling of the body
especially the face and the feet
 Anosmia – absence of smell
 Hyposmia – decrease sensitivity of the sense of smell
 Decreased visual acuity
 Papiledema – edema of the optic disc due to increase intracranial pressure
(choked disk)
 Diplopia – double vision
 Homonymous Hemianopia – blindness of the half of the visual field of
the same side
 Hemianopia – blindness of the visual field
 Anisocuria – inequality of the size of pupil
 Ptosis – drooping of the eyelid over the eye which may be caused by the
damage to the oculomotor nerve
 Opthalmoplegia – paralysis of the extraocular muscle
 23

5. Perceptual deficits
 Diminished proprioception – lack of awareness of where the various parts
are in relationship to each other and the environment
 Unilateral neglect syndrome – distortion in body image in which the
patient ignores the affected side.
 Anosognosia – apparent unawareness or denial of any loss or deficit in
physical functioning
 Agnosia – total or partial loss of the ability to recognize familiar objects or
persons through sensory stimuli.
 Apraxia – perceptual problem which involves inability to perform
purposeful movements in the absence of motor, sensory, or coordination
losses.
 Impaired spatial judgment – loss of the ability to judge distance or size, or
localize objects in space
 Impaired right and left discrimination
6. Emotional
 Emotional lability and unpredictability
 Depression
 Loss of self-control
 Decrease tolerance to stressful activities
 Fear, hostility, anger
 Feeling of isolation
 Withdrawal
7. Cognitive
 Memory loss
 Short attention span
 Lack of concentration
 Poor abstract reasoning
 Altered judgment
8. Language
 Alexia – inability to comprehend written words
 Agraphia – loss of the ability to write
 Aphasia – General term used to describe impairment of language function.
It is the inability to use and understand spoken or written words.
o Non-fluent aphasia (motor/expressive/Broca’s aphasia) –
understands what is said but cannot say the right word
o Fluent aphasia (sensory/receptive/Wernicke’s aphasia) – patient
cannot comprehend written or spoken words; able to speak but
uses words incorrectly
 24

o Mixed/Global aphasia – combination of expressive and receptive

aphasia
 Dysarthria – problem with the enunciation and articulation from the
interference of peripheral speech mechanisms such as muscles of tongue,
palate, pharynx or lips.

Medical Management for Ischemic Stroke

 Thrombolytic therapy
Thrombolytic agents are used to treat ischemic stroke by dissolving the blood clot
that is blocking blood flow to the brain. Recombinant t-PA is genetically engineered from
of t-PA, a thrombolytic substance made naturally by the body. It works by binding to
fibrin ad converting plaminogen to plasmin, which stimulates fibrinolysis of the
atherosclerotic lesion.
 Therapy for patients not receiving t-PA
o Elevation of the head of the bed to promote venous drainage and to lower
increased ICP.
o Possible hemicraniectomy for increased ICP form brain edema in a very large
stroke.
o Intubation with an endotracheal tube to establish patent airway, if necessary.
o Continuous hemodynamic monitoring.
o Neurologic assessment to determine if the stroke is evolving and if other acute
complications may include seizures, bleeding from anticoagulation, or
medication-induced bradycardia, which can result in hypotension and subsequent
decreased in cardiac output and cerebral perfusion pressure.
 Surgical Prevention
o Carotid endarterectomy – It is the main surgical procedure for selected patients
with TIAs and mild stroke which is also currently the most frequently performed
noncardiac vascular procedure. It is defined as the removal of an atherosclerotic
plaque or thrombus from the carotid artery to prevent stroke in patients with
occlusive disease of the extracranial cerebral arteries.
o Carotid stenting (with or without angioplasty) – It is a less invasive procedure
that is used, at times, for severe stenosis. It is used for selective patients who are
at high risk for surgery and its efficacy ccontinues to be investigated.

Medical Management for Hemorrhagic Stroke

 25

The goals of medical treatment for hemorrhagic stroke are to allow the brain to recover
from the initial insult (bleeding), to prevent or minimize the risk of rebleeding, and to prevent or
treat complications. Management may consist of bed rest with sedation to prevent agitation and
stress, management of vasospasm, and surgical or medical treatment to prevent rebleeding.

 Surgical management
o Patient with an intracranial aneurysm is prepared for surgical intervention as soon
as his or her condition is considered stable. The goal of the surgery is to prevent
bleeding in an unruptured aneurysm or further bleeding in an already ruptured
aneurysm. This objective is accomplished by isolating the aneurysm form its
circulation or by strengthening the arterial wall.
o An aneurysm may be excluded from the cerebral circulation by means of a
ligature or a clip across its neck. If this is not anatomically possible, the aneurysm
can be reinforced by wrapping it with some substance to provide support and
induce scarring.
o Less invasive endovascular treatments are now being used for aneurysms. Two
procedures include endovascular treatment (occlusion of the parent artery) and
aneurysm coiling (obstruction of the aneurysm site with a coil)
 26

II. HEALTH HISTORY

A. HISTORY OF PRESENT ILLNESS

On March 9, 2018 at 3:00 PM A day before admission Tata Ernest went to farm and
suddenly experienced headache and dizziness when he home tata ernest immediately tell her
daughter what she feels and her daughter gave her a warm water and he take a rest.

At 7:00 pm Tata ernest was rushed to RHU Banna accompanied by her daughter Lucile
complained of dizziness, headache and episode of nausea and vomiting, chest pain and weakness
with vital sign of 180/120 and the manage to give him captopril 25ml and advised to transefer
Emergency room. Tata ernest was transferred via ambulance to Mariano Marcos Memorial
Hospital and Medical Center at aroud 7:40 pm and was admitted by Dr. Ofelia C. Datu and Anna
Dominuque R. Sadian with admitting diagnosis Cvd Bleed Right Basal Gagalia Hypetension
uncontrolled

B. PAST HEALTH HISTORY

According to Mang Lucile Tata Ernest experienced common childhood illness such as
chickenpox, mumps and measles.

He had also experienced common ailments which include fever, headache, cough and
cold, diarrhea, and stomachache. These ailments were managed by taking prescribed drugs such
as Paracetamol 250 mg/ml for fever and headache 3 times a day.. 2 cups of oregano decoction
and kalamansi for cough.

For immunization, According to Manang Lucile Tata Ernest doesn’t have any
immunization. . In addition, there is no BCG scar on either of his shoulder. And doesn’t have any
allergy.

C. FAMILY HISTORY OF ILLNESS

 27

According to mang Lucile the daughter of Tata Ernest there was no illness that runs in
their family. His father and mother died to degenerative changes brought by old age. Tata Ernest
daughter said that they are all completely vaccinated.when they are sick these are managed by
taking prescribed drugs such as Paracetamol 250 mg/ml for fever and headache 3 times a day.. 2
cups of oregano.

The patient was 3rd among the four siblings his two siblings died due to edema and big
stomach. Currently the patient lives with his family

III. DEVELOPMENTAL DATA

Erik Erikson’s Psychosocial Development Milestones

Erikson considers life as composed of sequence of levels of achievement and each stage
indicates a certain tasks to be achieved. An achievement would mean a healthier personality
while failure means that the person would not be able to go to the next level and probably will
lead to regression.

Tata Ernest is 63 years old and belongs to the stage of maturity under the central task which is
Integrity vs. Despair (63 years to death). His developmental task is to achieve INTEGRITY
which includes acceptance of with and uniqueness of one’s own life, and acceptance of death.
Integrity is defined as a state of being complete and wholeness. DESPAIR, in contrast, is
exhibited by those people who feel a sense of loss, and contempt for others.

1. Acceptance of worth and uniqueness of one's own life – ATTAINED

- Tata Ernest claimed that he never regret his decisions happened in his life because it
will give big benefits to his family. In fact he was so happy to be here.

2. Acceptance of death – ATTAINED

- Tata Ernest stated that “ lumakay nakon, agrakaya met ti bagbagi kon ken isu met
amin papanan tayo isu nga maaccept ko nga dumteng to ti panakatay ko.”

Analysis: Erik Erikson’s Psychosocial Development Milestones the client attained all the tasks
required under this age.
 28

Robert Havighurst Developmental Task Theory

According to Havighurst, learning is fundamental to life and in order to have a

deeper insight on growth and development, one must understand it and recognize the premise
that human being continues to learn throughout life. According to his Developmental Theory,
once you have achieved the task successfully it gives you happiness and ease in attaining the
other tasks. However, if you failed to achieve those, it leads to unhappiness and feeling of
disapproval by the people around you. It also results in difficulty of achieving the later tasks.

There are 6 stages, which Havighurst described the growth and development of an individual
with particular task that must be achieved. The patient is 63 years old and belongs to late
maturity. The following tasks are very important to accomplish: Adjusting to decreasing physical
strength and health, adjusting to retirement and reduced income, adjusting to death of a spouse,
establishing an explicit affiliation with one’s age group, meeting social and civil obligations and
establishing satisfactory physical living arrangements Expected tasks on this stage:

1. Adjustment to decreasing physical strength and health- ATTAINED

 Tata Ernest admits that because of his old age there are many changes including
decline in his physical strength and health as an evidence of changing in working
capabilities. At present he was still able to go to the farm. He eats more vegetables
than meat.
2. Adjusting to retirement and reduced income- ATTAINED
 Tata Ernest had been admitted that because of his declining age he understand that
he does not need much money to live. It means that since he’s old, he can live
with little. In addition, he does not need anything else aside from the basic needs
in his family and others.
3. Adjusting to death of a spouse- NOT APPLICABLE
 Tata Ernest stated that his wife is still alive.
4. Establishing an explicit affiliation with one’s group- ATTAINED
 He was an active member of the Senior Citizens. Tata Ernest has a good
relationship with his fellow members and neighbours.
5. Meeting social and civic obligations- ATTAINED
 Tata Ernest also participates in barangay activities like attending meetings or
session and supports all the programs and projects of their barangay.
6. Establishing satisfactory physical living arrangement
 29

 According to Tata Ernest, he is satisfied with all the things that he had gone
through and contented with where and what he lives in.

Analysis: Tata Ernest achieved 5 out of the 6 of developmental task expected from his level of
maturity based on the acceptance in the adjustment towards decreasing physical strength, health
and reduce income. Adjusting to death of a spouse is not applicable because his wife is still alive.

VI. PATTERNS OF FUNCTIONING

Eating Pattern

Before Illness During Illness

He usually eats breakfast at Before Hospitalization During Hospitalization
around 5 am consisting of 2 He usually eats breakfast at At the hospital, he eats
cup of rice and 1 boiled egg around 5:00 am consisting of breakfast at around 7:00 am,
up and 2 tuyo with kamatis. 2 cup of rice and 1 boiled egg they gave 2 pandesal. For his
He takes his snack at around up and 2 tuyo with kamatis. lunch, he eats at around 11:30
10:00 a.m which consist of 1 He takes his snack at around a.m. consist of 1 piece of fish
pack(3 pieces) of skyflakes 10:00 a.m which consist of 1 and one cup of rice. In
and 270ml bottled of pack (3pieces) of skyflakes. addition, he also eat one piece
softdrink. For his lunch, he For his lunch, he eats at of banana. For dinner at
eats at around 11:30 a.m. his around 11:30 a.m. his usual around 7:00 p.m which
usual lunch is 2 cup of rice lunch is 2 cup of rice and 1 consist of one cup of inabraw
and 1 cup of meat and sitaw. cup of meat and sitaw. He and a one cup of rice.
He eats his dinner at around eats his dinner at around 7:00 According to the patient’s
7:00 p.m with one cup of p.m with a half cup of daughter, the patient could
“inabraw and meat” and a 1 “inabraw and meat” and a 1 not consume all the hospital
and1/2 cup of rice. and 1/2 cup of rice. ration.

Analysis:

There is no change in the eating pattern of Mr. Baga before illness and before
hospitalization. However, there is clearly a change before and during hospitalization due to his
condition. From above, his frequency in eating has decreased because during his hospitalization,
 30

he does not eat snacks. During hospitalization, he could not consume the hospital ration because
he didn’t have appetite.

Drinking Pattern

Before Illness During Illness

Throughout the day, he Before Hospitalization During Hospitalization
usually consumes 7-8 glasses Tata Ernest usually consumes At the hospital, he drinks 2-3
of water (1680-1920). In the same amount of water glass of water and a half cup
addition, he also drinks 1 cup throughout the day as she did of milk (120 ml) per day.
of coffee (240 ml) during before illness. However, he is supported
breakfast. In the evening 1-2 with IVF. To sum it all up, he
glasses of water (240-480 consumes 600-840 ml of
ml). His total fluid intake is fluids a day.
approximately 2160-2640
ml/day.
Analysis:

There is no change in the drinking pattern of Tata Ernest before illness and before
hospitalization. But there is a change before and during hospitalization of the patient. He cannot
drink his usual fluid intake because of her condition. He is supported by an intravenous fluid
preventing dehydration.

Bathing Pattern

Before Illness During Illness

Before Hospitalization During Hospitalization
 31

He usually takes a bath in the He usually takes a bath in the At the hospital, he stated that
morning at 5:30 a.m and morning at 7:00 a.m and he did not take a bath at all.
evening at 6:00 p.m. He evening at 6:00 p.m. He Only the significant other
usually takes 20-30 minutes usually takes 15 minutes of does bed bath using a luke-
of bathing. He uses head and bathing. He uses head and warm water and safeguard
shoulder as his shampoo and shoulder as his shampoo and soap.
Safeguard as his body soap. Safeguard as his body soap.
Analysis:

There is change in the bathing pattern of the patient because of the time he takes a bath
and the duration of his bathing has changed. He couldn’t do take a bath during hospitalization
due to his condition.

Sleeping Pattern

Before Illness During Illness

He usually sleeps at around Before Hospitalization During Hospitalization
10:00 p.m and often watching The patient’s sleeping time According to Mang Lucile
television before going to and duration is the same as tata ernest he sleep at 8:00
sleep. He usually wakes up before illness. p.m and wake up everytime
early at 5:00 a.m. He takes a the nurse rounds.
nap for 1 hour from 12-1 p.m
everyday. His total sleeping
hours is 8 hours per day
Analysis:

Bladder Pattern

Before Illness During Illness

Before Hospitalization During Hospitalization
 32

He urinates yellowish urine He stated that there was no At the hospital, the color of
about 8-10 times a day change in his bladder urine is yellowish urine. He
(approximately 180 ml per elimination before has an IFC. His total output
voiding). His total urine hospitalization. per day is 1000-1840 ml per
output is approximately 1440- day.
1800.
Analysis:

There is a change in the bladder elimination of the patient. The amount of urine changed
between before and during hospitalization because of the amount of intake per day

Bowel Pattern

Before Illness During Illness

He usually defecates once a Before Hospitalization During Hospitalization
day in the morning. He also The patient stated his bowel During the stay of the patient
characterized his stool as elimination had the same in the hospital, he usually
yellowish to brownish in characteristics, amount and defecates once a day and the
color, moderate in amount frequency before illness color is brown and semi-
and its consistency is well formed.
and formed.

Analysis:

There is no change in the bowel elimination of the patient before and during illness.

VII. LEVELS OF COMPETENCY

PHYSICAL COMPETENCY

Before Illness During Illness

Before Hospitalization During Hospitalization
 33

Tata Ernest does not have any Before hospitalization, the At the hospital, Tata Ernest
difficulty in performing his patient is still able to perform can still do his activities of
activities of daily living such the same activities such as daily living. However, he is
as eating, bathing and eating, bathing, and dressing limited to activities that
dressing without supervision. without help. requires minimal exhaustion.
Every morning at around 7:00 He could still eat without
a.m he go in their farm. help.
Analysis:
There is no change in the physical competency before illness and before hospitalization
because he could still perform the same activities. But there is clearly a change before illness and
during hospitalization due to difficult of breathing. However, he could still eat without
supervision.

EMOTIONAL COMPETENCY

Before Illness During Illness

Acording to Mang Lucile Before Hospitalization During Hospitalization
Tata Ernest shows his According to Mang Lucile During the nurse patient
feelings to those person he’s Tata Ernest shows her interaction, Tata Ernest was
living with whenever he feels feelings to those person he’s able to exhibit pleasant
sad or happy also when he living with whenever he feels emotions expressing herself
needs something. He shows sad or happy also when he comfortably. When I asked
appropriate emotions in every needs something. He shows about his condition, he
situation. appropriate emotions in every showed a little bit of smile
situation. on his face and
disappointment.
Analysis:
There is no change in his emotional competency because he is showing the appropriate
emotions.

COGNITIVE COMPETENCY

Before Illness During Illness

Before Hospitalization During Hospitalization
 34

According to Mang Lucile He can still oriented to time, At the hospital, the patient’s
Tata Ernest is oriented to date, place, person and mental functioning stays the
time, date, place, person, and situation. He is able to make same. He could still oriented
situation. He could make decisions for himself and and recall the things.
decisions for himself and family in regards to problem.
family in regards to problem. He is able to consider and
He is able to consider and understand the opinions of
understand the opinions of others.
others.
Analysis:

There is no change in the cognitive competency of the patient. The mental capacity is still
the same before illness and during hospitalization. His condition does not alter the way he thinks.
He is still able to understand every word that he heard.

SOCIAL COMPETENCY

Before Illness During Illness

According to Mang Lucile Before Hospitalization During Hospitalization
Tata Ernest often goes out to His social competency is still During the nurse patient
their house and mingles with the same as before illness. interaction, he was able to
his neighbors. He also give socialize by communicating
smile to people whom passed and interacting with the
by. However, he is also a people around him.
member of Senior Citizen.
Analysis:

There is no change in social competency of the patient. He is able to socialize by

communicating and interacting with the people around him.

SPIRITUAL COMPETENCY

Before Illness During Illness

 35

Tata Ernest has a good Before Hospitalization During Hospitalization

relationship with God. And The patient stated that his He prays during hospital
always pray at night before spiritual competency had the because he wanted to get well
going to bed not just for same as before illness as fast as he can by asking it
himself, but also for his from God.
family and for other people.
Analysis:

There is no change in the spiritual competency of Tata Ernest before and during
hospitalization.

VIII. PHYSICAL ASSESSMENT

March 12, 2018 @ 1:00 pm

Tata Ernest was lying on bed, awake, weak in appearance. With an Indwelling Foley
catheter connected to urine bag draining yellow urine with a level of 150 ml. He was wearing a
white T-shirt and black shorts. On his right hand, he has an IVF of PNSS 1000 ml @ 800 cc
level, regulated to KVO, infusing well.

VITAL SIGNS:

BP: 120/90 mmHg (right arm)

TEMP: 36ºC per axilla

PR: 79 bpm

RR: 20 bpm

WEIGHT: 62 kgs. HEIGHT: 166 cm BMI: 22.5 (Normal)

GCS: E:4; V:4; M:3 =11 Moderate

HEAD TO TOE ASSESSMENT:

A. HEAD

Skull

 Normocephalic (head is proportional to the body size)

 36

 Symmetrically rounded

Hair and Scalp

 Thin short hair

 Variable amount of hair
 Scalp appears clean and dry

Face

 Symmetrical facial movements

 Sagging skin
 Face is brown in color

Eyes

 Thin eyebrows and eyelashes

 Equally distributed eyelashes
 Conjunctiva is pinkish, sclera is white
 Pupils equally round , react to light and accommodation

Ears

 Color is same as the face

 Equal in size and similar in appearance
 Aligned pinna with the outer cantus of the eye
 With minimal amount of cerumen seen

Nose

 External color is the same as the face

 In the midline of the face
 Nasal septum intact and in midline
 Asymmetrical in terms of the position of the nose

Mouth

 Lips is dark in color

 Dry lips
 Tongue is pink and moist
 Tongue is able to move sideways, up and down
 Gums is pink and moist
 Uvula is in midline
 Absence of teeth
 37

 Symmetrical in position

Neck

 With the same color as the face

 No tenderness upon palpation
 Able to extend to extend, hyperextend, turn right and left
 Able to rotate at 180 ֯

Chest

 Skin is brown in color

 With symmetrical chest expansion

Abdomen

 Brown in color
 Umbilicus is in midline
 Soft and non-tenderness upon palpation
 Abdomen is flat

Upper Extremities

 With brown in color

 Arms equal in size and symmetrical
 Skin is sagging
 With trimmed nails
 Nail beds are brown in color
 Capillary refill returns within 2 seconds
 Able to flex, extend, abduct, adduct and raise both extremities without difficult or
discomfort
 With a pulse rate of 79 bpm
 With an IV at right hand and Iv sites are not swollen

Lower Extremities

 Skin is brown in color

 Legs are symmetrical
 Able to flex, extend, abduct, adduct and raise both extremities without difficult or
discomfort
 With trimmed nails
 38

 Capillary refill returns within 2 seconds

 Edema on Lower extremities

IX. DIAGNOSTIC PROCEDURES

A. Complete Blood Count (CBC)

The complete blood count (CBC), a screening test, is one of the most frequently ordered
laboratory procedures. It gives a fairly complete picture of all blood’s formed elements. It also
analyzes the three major types of cells in blood: red blood cells, white blood cells, and platelets
in a given unit of blood. Hematologists also examine blood samples under a microscope to
identify abnormal blood cells and diagnose blood diseases. This laboratory test can detect
presence of anemia, infections, cancer, and other blood diseases. It also determines the severity
of such disorders and compare the status of specific blood elements.
Components of CBC:
a. Hemoglobin – It is the main component of red blood cells. Its main function is to
carry oxygen from the lungs to the body tissues and to transport carbon dioxide,
the product of cellular metabolism, back to the lungs. Hemoglobin is the measure
of the total amount hemoglobin in the blood.
b. Hematocrit – It measures the percentage of red blood cells in the total blood
volume.
c. Red Blood Cell (RBC) – It is the determination of the number of red cells found
in the each cubic millimeter of whole blood.
d. Mean Cell Volume – The MCV describes individual red cell size. It is the ratio of
the volume of packed cells to the red cell count.
e. Mean Cell Hemoglobin –It is the average mass of hemoglobin per red blood cell
in a sample of blood. It is reported as part of a standard complete blood count.
f. Mean Cell Hemoglobin Concentration – It measures the concentration of
hemoglobin in a given volume of packed red blood cells.
g. White Blood Cell (WBC) – The total WBC count is the absolute number of WBC
(leukocytes) circulating in a cubic millimeter of blood. WBCs defend against
invading organisms through phagocytosis and produce or transport and distribute
antibodies to help maintain immunity.
h. Differential Count – It is done to identify the five types of leukocyte cells on a
stained slide of peripheral blood. The cells are counted and the differential count
 39

is expressed in relative percentage values, which are mathematically correlated to

their absolute values.
h.1. Segmenters – Their protective function includes phagocytosis.
h.2 Lymphocytes – Their protective function is in antibody production and
humoral immunity.
h.3. Monocytes – Their protective function is phagocytosis against
bacteria and large protozoa such as fungi and parasites.
h.4. Eosinophils – They play a role in allergic reactions, possibly
inactivating histamine.
h.5. Basophils – They contain histamine and heparin and appear to be
involved in immediate hypersensitivity reactions.
i. Platelets – These are large, non-nucleated cells derived from the megakaryotes
produced in the bone marrow that release a substance that begins the coagulation
process.
Date Ordered: March 12,2018
Purpose:
The procedure was done to serve as baseline data of the blood components of the patient.

Examination Result Ref. Range Significance

Hemoglobin 165.00 140-175 Normal
Hematocrit 0.49 0.41-0.50 Normal
Red Blood Cell 5.43 4.5-5.9 Normal
MCV 90.10 80-100 Normal
MCH 30.70 27-32 Normal
MCHC 30.90 31-35 Normal
RDW 12.80 12-16 Normal
White Blood Cell 15.14 4.50-11.00 High
Differential Count
Segmenters 0.65 0.50-0.70 Normal
Lymphocyte 0.21 0.20-0.40 Normal
Monocyte 0.11 0.02-0.08 High
Eosinophil 0.02 0.01-0.04 Normal
 40

Basophil 0.01 1.00-0.01 Normal

Platelet Count 223.00 150-450 Normal

Analysis:

From the retrieved results it is clear that Tata Ernest has a high concentration of WBC
(indicates infection), and a high level of monocytes indicating it as a viral type of infection

Nursing Responsibility Rationale

1. Check the doctors. To avoid error
2. Confirm the patient’s name To prevent mistake.
3. Explain the procedure to the client or To gain cooperation and increase her
for this case the significant others. awareness regarding to cooperation to be
done.
4. Make a laboratory request and forward To inform the Medical Technologist
it to a laboratory.
5. Encourage patient to eat foods rich in To supplement iron lost.
iron (etc. green leafy vegetables and
moderate amount of red meat)
6. Encourage vitamin C intake. To boost the immune system.
7. Instruct the patient to have enough To lessen the body’s oxygen demand and give
rest. time for recovery.

B. Blood Chemistry
Blood chemistry tests are often ordered prior to surgery or a procedure to examine the
general health of a patient. This blood test, commonly referred to as a Chem 7 because it
looks at 7 different substances found in the blood, is routinely performed after surgery as
well. The serum chemistry profile is one of the most important initial tests that are
commonly performed. A blood sample is collected from the patient. The blood is then
separated into a cell layer and serum layer by spinning the sample at high speeds in a
machine called a centrifuge. The serum layer is drawn off and a variety of compounds are
 41

then measured. These measurements aid in assessing the function of various organs and
body systems.
Components of Blood Chemistry:

• Blood Urea Nitrogen (BUN) - BUN is a measure of kidney function. A high level may
indicate that the kidneys are functioning less than normal.

• Creatinine – Creatinine is produced by the body during the process of normal muscle
breakdown. This part of blood chemistry profile measures the serum creatinine level.

• Glucose - This test shows the level of glucose in the blood.

• Potassium - This test shows the level of potassium in the blood. Potassium plays an
important role in muscle contractions and cell function. Both high and low levels of potassium
can cause problems with the rhythm of the heart so it is important to monitor the level of
potassium.

• Sodium - This portion of the test shows the amount of sodium present in the blood. The
kidneys work to excrete any excess sodium that is ingested in food and beverages.
Sodium levels fluctuate with dehydration or over-hydration, the food and beverages
consumed,diarrhea, endocrine disorders, water retention (various causes), trauma and
bleeding.
The procedure was done to serve as baseline data of the blood chemistry of the patient
and to determine abnormalities that may help in providing appropriate interventions.

Date Ordered: March 12,2018

Purpose: This was done to my client to determine if there are any abnormalities present in her
urine.

Test Value References Significance

Blood Urea Nitrogen 6.35 1.7-8.3 Normal

Creatinine 23.5 44.2-150.3 Normal

Sodium 133.2 136-150 Low

Potassium 4.16 3.4-5.4 Normal

 42

Analysis: Based on the results on the table, sodium is low because of the shifting of fluid from
intravascular to interstitial compartments indicating hyponatremia.

Nursing Responsibilities:
Nursing Responsibilities Rationale

1. Check the doctor’s order. To ensure correct procedure to be done.

2. Check if the laboratory request form is In order to inform the medical technologist
properly filled up and sent to the about the exact procedure to be done.
laboratory.
3. Explain to the patient/watcher the To increase patient/watcher’s awareness, gain
procedure, its purpose, process of cooperation and allay anxiety of the patient,
specimen collection and the stinging and to determine if there is a need for
sensation that may be felt. Ensure if the reemphasizing the procedure.
patient/watcher understood the
procedure and its nature well. Clarify
their doubts and answer questions
accordingly.
4.Document the procedure. Documentation serves for legal purposes.

C. LIPID PROFILE
Lipid Profile is a test which measures the concentrations of fats and cholesterol in the
blood, and can be used to assess so-called ‘good cholesterol’ versus ‘bad cholesterol’ levels. The
significance of this test is the relationship between an abnormal lipid profile and atherosclerosis,
the cause of many cases of heart disease and strokes.
Date ordered: March 9,2018
Purpose:
The procedure was done to serve as baseline data and to determine any abnormalities that
help in providing immediate interventions. This was also done to determine the cholesterol level
of the patient.

Results:
Test Value Reference Significance

Lipid Profile
 43

Cholesterol 6.36 <5.17 High

Triglycerides 1.30 <2.28 Normal

HDL Cholesterol 0.90 >1.55 Low

LDL Cholesterol 4.33 >3.36 High

Analysis:

Based from the results presented, cholesterol and LDL cholesterol are high, and HDL
Cholesterol is low because of the faulty nutritional status of the patient and such results indicates
high intake of fatty foods and rich cholesterol meats.

Nursing Responsibilities:
Nursing Responsibilities Rationale

Before the procedure:

1. Check the doctor’s order. To ensure correct procedure to be done.

2. Check if the laboratory request form is In order to inform the medical technologist
properly filled up and sent to the about the exact procedure to be done.
laboratory.
3. Explain to the patient/watcher the To increase patient/watcher’s awareness, gain
procedure, its purpose, process of cooperation and allay anxiety of the patient,
specimen collection and the stinging and to determine if there is a need for
sensation that may be felt. Ensure if the reemphasizing the procedure.
patient/watcher understood the
procedure and its nature well. Clarify
their doubts and answer questions
accordingly.
4. Instruct patient to have fasting for at To get more accurate results.
least 10 hours prior to the procedure.
5. Document the procedure. Documentation serves for legal purposes.

D. CT-SCAN

A CT scanner directs a series of X-ray pulses through the body. Each X-ray pulse lasts
only a fraction of a second and represents a “slice” of the organ or area being studied. The slices
 44

or pictures are recorded on a computer and can be saved for further study or printed out as
photographs.

Date ordered: March 9,2018

Purpose:

This procedure is done to observe any damage on the extent of damages of the head and brain.

Results: March 14, 2018

Cranial CT-SCAN-PLAIN

Multiple axial tomographic sections of the cranium without contrast media were obtained.

The CT images reveal follow up study to one dated 09 March 2018 shows no significant interval
changes in size and attenuation of the right thalamocapsular hemorrhage. Margins now appears
slightly irregularly indicative of clot retraction.
Minimal bleed still seen at the right lateral ventricle.
Tiny hypodensity noted at the left caudate and left lentiform nuclei.
CSF-focus at the left frontotemporal region region likely an arachnoid cyst.
Patchy ill-defined hypodensites are seen in theperiventricular white matter and centrum
semiovale.
The cortical sulci, cerebellar sulci, and lateral fissures are prominent with ex-vacuo dilatation of
the ventricles
The midline structures are not displaced.
Pineal gland and choroid plexus calcifications are seen.
Calcifications line the vertebral and internal carotid arteries.
The sella and posterior fossa including the brainstem, cerebellopontine angles and basal cistems
are unremarkable.
The paranasal sinuses, mastoid air cells, and orbits are normal as visualized
The calvarium is intact. The extracalvarial soft tissues are unremarkable.
IMPRESSION:
Right thalamocapsular hermorrhage with interval evidence of clot retraction.
Lacunar infract, left basal gangalia
 45

Microvascular white matter ischemic changes.

Cerebrocerebellar athrophy.
Arachnoid cyst, left frontemporal region.
Atherosclerosis
Nursing Responsibilities

Nursing Responsibilities Rationale

1. Check doctor’s order. To avoid committing errors

2. Explain or reinforce the client about the To obtain cooperation and to decrease possible
procedure and its importance. anxiety of the client.

3. Provide consent for the procedure For legal purposes

5.Document the procedure. Documentation serves for legal purposes.

TREATMENT

1. INTRAVEOUS THERAPY (PNSS 1000 L)

Date ordered: March 9,2018

Intravenous (IV) Therapy is the insertion of a needle or a catheter or cannula into a vein
based on physician’s written prescription. Intravenous delivery permits a rapid effect and a
maximal degree of control over the circulating levels of the drug. It is also given as a
replacement of fluids, administration of IV medication, and provision of nutrients when no other
route is available and restores acid base balance.

Normal Saline is a sterile, nonpyrogenic solution for fluid and electrolyte replenishment.
It contains no antimicrobial agents. The pH is 5.0 (4.5 to 7.0). It contains 9 g/L Sodium Chloride
with an osmolarity of 308 mOsmol/L. It contains 154 mEq/L Sodium and Chloride. It is
indicated as a source of water and electrolytes. This Isotonic solution has the same tonicity with
plasma. This means that the osmotic pressure is the same in the inside and outside of the living
 46

cell that is in contact with the solution. Therefore, water neither enters nor leaves the cell, the
water rate in terms of movement is the same.
Purpose:

This was given to the client as a supportive therapy for his condition and to
maintain proper hydration.

Nursing Responsibility Rationale

1. Check the doctor’s order To avoid error
2. Ask the patient’s name. To ensure safety for identify.
3. Explain the purpose and procedure to the To gain cooperation from the client.
client and family about the management.
4. Prepare all necessary materials or To prevent further occurrence of infection.
equipment aseptically.
5. Position the arm or the site of IV infusion To maintain the patency of the IV line.
comfortably.
6. Regulate IV fluid to the desired rate. To prevent fluid overload.
7. Instruct the patient to minimize To prevent dislocation of the needle or
unnecessary movements especially on the infiltration.
infusion site.
8. Change the solution container before it is To prevent embolism.
completely emptied.
9. Avoid client to manipulate the IV fluid. To prevent infiltration.
10. Fill up completely the IV sheet in the For legal purposes.
patient’s chart.
11. Regularly check the iv site for signs of Prevent infection
phlebitis.

2.URINARY CATHETERIZATION

Date of order: March 9,2018

 47

Urinary catheterization involves the induction of a catheter through into the urinary bladder. An
indwelling Folley catheter was inserted to provide continuous bladder drainage and irrigation. It contains
a second, smaller tube throughout its length on the side. This tube is connected to a balloon near the
insertion tip. After the catheter insertion, the balloon is inflated to hold the catheter in place within the
bladder.

Purpose:

The purpose of the catheter insertion is to provide for intermittent, continuous bladder
drainage and irrigation since client is unable to go to the comfort room for elimination purposes
and has difficulty in verbalizing her needs because of inability to speak. Moreover, this catheter
is inserted to measure the amount of urine output.
Nursing Responsibilities:
Nursing Responsibilities Rationale

1. Check the doctor’s order. To avoid committing errors

2. Inform the client and the watcher the To gain cooperation

purpose of the procedure.

3. Prepare the materials to be used. To save time and effort

4. Position the client properly on supine To relax abdominal muscles

position with knees flexed and thighs
externally rotated.
5. Wear gloves. To prevent introduction of microorganisms

6. Drape the client properly To maintain privacy

7. Lubricate the insertion tip of the To reduce friction

catheter with water soluble lubricant
8. Hang the urine bag freely, must be To prevent backflow of the urine
lower than the point of insertion

9. Change IFC every three days To prevent infection

10. See to it that the drainage bag does not To prevent ascending infection.
touch the floor.
11. Do perineal care. To prevent infection and irritation.
 48

12. Observe urine output, presence of To have immediate intervention with regards to
discoloration, and sediments. Report abnormal results.
any abnormalities of urine.
13. Document the time and date of For legal purposes
insertion.

3.INTAKE AND OUTPUT MONITORING

Date of ordered: March 10, 2018

Measurement and recording of all fluid intake and output provides important data of the
client’s fluid and electrolyte balance. It also serves as a parameter for the management rendered
to the client.

Purpose: This management was done to assess fluid balance. Measuring fluids is necessary since these
fluids play significant roles in the improvement of the client.

Nursing Responsibility Rationale

1. Inform client, family members that To obtain cooperation of the client and family.
accurate measurements of the client’s fluid
intake and output are required are also
included the rationale of this management.
2. Specify the time and fluid intake and record For accurate measurement of fluid intake.
it such as: oral fluids like water, milk, juices,
soap or cream, parenteral fluids and IV
medications and cyclis.
3. Specify the time and fluid output as to For accurate measurement of intake and
urinary output and vomitous (if there is). output.
4. Provide a calibrated or improvised For accurate measurement of urine output.
measuring device that may be used in
measuring the input and output of the patient.
5. Fluid input and output measurements are To determine significant changes in the fluid
totalled at the end of the shift. status of the client.
 49

DRUGS STUDY

1.Name of drug: Lactulose

Date Ordered: March 9,2018

Generic Name: Lactulose

Brand Name:

Drug Classification: Hyperosmotic laxative

Dosage and Frequency: 30cc OD @ HS

Route: Oral

Mechanism of Action: A disaccharide which increases water content and softens the stool. .
Indication: This drug is given to the patient to relieve constipation.

Nursing Responsibilities:
Nursing Responsibilities Rationale
1. Check for 10 R’s in administering the drug. To prevent committing errors.
2.Monitor for side effect like nausea and To address side effects immediately.
vomiting
3.Notify physician if diarrhea persists more Diarrhea is a sign of overdosage.
than 24-48 hours.
4.Provide high fiber diet to the patient. To prevent constipation.

5.Provide comfort measures To help to cope up with drug effects.

2.Name of Drug: Amlodipine

Date Ordered: March 9,2018

Generic Name: Amlodipine

Brand Name: Norvasc

Drug Classification: Antihypertensive

 50

Dosage and Frequency: 5mg OD

Route: Oral

Mechanism of Action: Is a diphyridine calcium antagonist (calcium ion antagonist or calcium-

channel blocker) that inhibits the transmembrane influx or calcium ions into vascular smooth

Indication: It was given to the patient to lower blood pressure

Nursing Responsibility Rationale

1. Check Doctor’s Order To protect self from illegal actions.
2. Observe the 10 R’s To make the treatment regimen effective
3. Monitor blood pressure frequently during Because drug induced vasodilation has a
initiation of therapy. gradual onset, acute hypotension is rare.

4. Assess for signs and symptoms or adverse To assure immediate intervention or action.
effects of the drug. Inform the physician
about abnormal findings

5. Provide a conducive environment for the Conducive environment could relieve and
patient. could lessen the manifestations of high blood
pressure.

6. Limit fluid intake as ordered. To prevent increase in blood volume thus

preventing increase in blood pressure.

3.Name of drug: Omeprazole

Date Ordered: March 9,2018

Generic Name: Omeprazole

Brand Name: Losec

Drug Classification: Proton Pump Inhibitors

Dosage and Frequency: 40mg OD

Route: Oral
 51

Mechanism of Action: A proton pump inhibitor compound that is a gastric acid pump inhibitor.
Supresseses gastric acid secretion by inhibiting the H + , K+-ATPase enzyme system the acid
(proton H+) pump in the parietal cells.Suppresses gastric acid secretion relieving gastrointestinal
distress and promoting ulcer healing.

Indication: It was given to the patient to decrease the gastric acidity of the stomach cause by
different medications given to patient.

Nursing Responsibility Rationale

1. Check doctor’s order. To avoid medication ERROR
2. Observe 10 R’s in the administration of To avoid mistake.
drug
3.Give before meals, probably in the morning To prevent GI irritation
4.Tell patient to swallow tablets or capsules Drug may need to be discontinued
whole and not open crush or chew them
5.Advise patient to report immediately about Drug may need to be discontinued
abdominal pain or diahrea

4.Name of drug: Vitamin B complex

Date Ordered: March 11, 2018

Generic Name: Vitamin B complex

Brand Name: Aduvit

Drug Classification: vitamins and minerals

Dosage and Frequency: 1 tab BID

Route: Oral

Mechanism of Action: The B complex vitamin act as coenxyme and essential for the
metabolism of proteins carbohydrates and fatty acids.
 52

Indication: Treatment for promoting healing, strong immune system, and healthy nervous
system. B vitamins help with the production of antibodies

Nursing Responsibility Rationale

1. Verify the doctor’s order. To prevent errors and have a general
awareness
2. Check 10 R’s in the administration of drug. To prevent from committing errors.
3. Check for sensitivity of the drug or allergic To check for any reaction.
history of the patient.
4. Monitor the patient of N/V after For vitamin B toxicity
administering the vitamin B
5. Inform the relatives about the side effect of To aware of the side effects of the medication
the vitamin B given.

5.Name of drug: Paracetamol

Date Ordered: March 11, 2018

Generic Name: Paracetamol

Brand Name: Calpol

Drug Classification: Analgesic

Dosage and Frequency: 500mg 1 tab q6

Route: Oral

Mechanism of Action: Relieves pain by inhibiting prostaglandin synthesis at the CNS but does not
have anti-inflammatory action because of its minimal effect on peripheral prostaglandin synthesis.

Indication: Treatment for fever.

Nursing Responsibility Rationale

1. Check Doctor’s Order To ensure proper dosage and to maintain the
potency of the drug.
 53

2. Observe the 10 R’s To make the treatment regimen effective

3. Assess patients fever or pain; type of pain To indicate baseline data and monitor drugs.
location, intensity, duration, temperature
4. Be alert for signs of reactions To establish proper precaution
5.Provide comfort measures To help to cope up with drug effects.

6.Name of drug : Mannitol

Date Ordered: March 11,2018

Generic Name: Osmotic Diuresis

Brand Name: Osmitrol

Drug Classification: osmotic diuretic

Dosage and Frequency: 100 cc IV q 4 defer if BP <90/60 mmHg

Decrease Mannitol to 75 cc q 4

X 3 doses then 50 cc q 4

X 3 doses then D/C

Route: IV

Mechanism of Action: Increases the osmotic pressure of the glomerular filtrate, thereby
inhibiting reabsorption of water and electrolytes

Indication: It is given to reduce patient’s cerebral edema.

Nursing Responsibility Rationale

1. Check Doctor’s order. To have general awareness.
2. Check for 10 R’s in administering the drug. To prevent from committing errors.
 54

3.. Observe infusion site frequently for Extravasation may cause tissue irritation and
infiltration. necrosis.

4. Assess for signs and symptoms or adverse Inform the physician about abnormal findings.
effects of the drug such as headache, To assure immediate intervention or action.
confusion, tachycardia, chest pain,
dehydration, hypo/hypernatremia,
hypo/hyperkalemia.

5. Limit fluid intake as advised. To prevent further cerebral edema.

6. Monitor urine output accurately. To determine the effectiveness of the

treatment regimen.

7. Position the patient in semi or high fowler’s To decrease cerebral edema via pull of gravity
position with assistance. of excessive fluids.

8.if drug is to discontinued have the drug to To prevent sudden hypotension of the patient
be discontinued gradually

7.Name of drug: Furosemide

Date Ordered: March 12, 2018

Generic Name: Furosesmide

Brand Name: Lasix

Drug Classification: Loop diuretic

Dosage and Frequency: 80mg q8

Route: IV

Mechanism of Action: Thought to inhibit sodium and chloride reabsorption from ascending
loop henle and distal renal tube

Indication: Treatment for edema

Nursing Responsibility Rationale

 55

1. Verify the doctor’s order. To prevent errors and have a general

awareness
2. Check 10 R’s in the administration of drug. To prevent from committing errors.
3.Monitor Vital signs For baseline data Be alert to changes inBP.
4. Advise the patient to adhere to the To avoid withdrawal of symptoms

prescribed regimen
5. Provide comfort measures To help patient to cope with drug effects

8.Name of drug: Paracetamol

Date Ordered: March 12, 2018

Generic Name: Paracetamol

Brand Name: Aeknil

Drug Classification: Analgesic

Dosage and Frequency: 300mg now then q4 PRNx headache

Route: IV

Mechanism of Action: Relieves pain by inhibiting prostaglandin synthesis at the CNS but does not
have anti-inflammatory action because of its minimal effect on peripheral prostaglandin synthesis.

Indication: Treatment for fever.

Nursing Responsibility Rationale

1. Check Doctor’s Order To ensure proper dosage and to maintain the
potency of the drug.
2. Observe the 10 R’s To make the treatment regimen effective
3. Assess patients fever or pain; type of pain To indicate baseline data and monitor drugs.
location, intensity, duration, temperature
4. Be alert for signs of reactions To establish proper precaution
5.Provide comfort measures To help to cope up with drug effects.
 56

8.Name of drug: Tramadol

Date Ordered: March 12, 2018

Generic Name: Tramadol

Brand Name: ultram

Drug Classification: Analgesic

Dosage and Frequency: 50 mg q8

Route: IV

Mechanism of Action: Binds to opiate receptors in the CNS causing inhibition of ascending pain
pathways, altering the perception of response to pain, also inhibits the reuptake of norepinephrine and
serotonin, which also modifies the ascending pain pathway

Indication: Management for pain

Nursing Responsibility Rationale

1. Check Doctor’s Order To ensure proper dosage and to maintain the
potency of the drug.
2. Observe the 10 R’s To make the treatment regimen effective
3. Monitor bowel bladder function To prevent constipation
4. Reassess patient level of pain at least For discontinuation
30minutes after administration
5.Warn patient not to stop the drug abruptly To prevent withdrawal

X. ON GOING APPRAISAL

March 11, 2018 @ 1:00 pm

Vitals Signs:
 57

BP: 120/90 mmHg

TEMP: 36.5 ֯ C

PR: 82-85bpm

RR: 21 bpm

On the first day of appraisal, Tata Ernest was lying on bed, awake, slightly weak in
appearance. With an Indwelling Foley catheter connected to urine bag draining yellow urine with
the level of 150 ml. He was wearing a white T-shirt and orange shorts. On his right hand, he has
an IVF of PNSS 1000 ml @ 450 cc level, regulated to KVO, infusing well iv site not swollen.

He was seen and examined by Dr.Anna Domique R.Sadian at around 8:00 a.m with new
orders.