1

CHAPTER I
INTRODUCTION AND DATA BASE
This chapter deals with the introduction about cerebrovascular disease, the objectives of
this study, the demographic data, and the health history of the patient, Gordons Functional
Health Patterns, and the family genogram.

INTRODUCTION
Cerebrovascular diseases (CVD) are a group of conditions that affect the circulation of
blood to the brain, causing limited or no blood flow to affected areas of the brain. One example
is atherosclerosis, wherein, high cholesterol levels coupled with inflammation in areas of the
arteries in the brain can cause the cholesterol to build up in the vessel in the form of a plaque.
Thus can limit, or completely obstruct, blood flow to the brain, causing a stroke, transient
ischemic attacks, which can result to a variety of other health complications such as Dementia.
Hypertension is also one of the most important causes that damage the endothelial lining of the
blood vessel which exposes the collagen to circulating platelets causing them to aggregate and
initiate a repairing process which is not always complete and perfect. Uncontrolled chronic
hypertension permanently changes the vulnerable fluctuation of blood pressure. A fall in blood
pressure during sleep can lead to a marked reduction of blood flow in the narrowed blood vessel
causing ischemic stroke in the morning. Conversely, a sudden rise in blood pressure due to
excitation during the daytime can cause tearing of the blood vessels resulting in intracranial
haemorrhage. Primarily people who are elderly, diabetic, smoker, or with a history of ischemic
heart disease, have increased risk for cerebrovascular accidents such as an Ischemic, or even a

hemorrhagic stroke. This would affect other organ systems secondary to the neuro-deficits, like
the muscular system, affected by atrophy of disuse from a plegia.
CVD is the most disabling of all neurologic diseases. Approximately 50% of survivors
have a residual neurologic deficit and greater than 25% require chronic care. Cerebrovascular
disease mortality in the Philippines was studied from the existing vital statistics for 2000-2008.
Death rates from cerebrovascular diseases increased enormously both in men and women. This
increase in mortality was seen in all age groups. The age-standardized mortality rate in men rose
from 33.3 in 2000 to 78.0 in 2005, and that of women from 15.4 to 34.5. The male to female
ratios in the age-standardized death rates increased during this 9-year period. Age-standardized
mortality increased clearly in the male population but decreased in the female population of the
Philippines. This excess mortality in males is mostly due to the increased cerebrovascular disease
death rate. This is a clear example of how chronic non-communicable diseases are becoming
major health problems in countries where they previously have not been prevalent. Immediate
preventive measures are needed in order to control cardiovascular diseases in countries, such as
ours, where disease rates are rapidly increasing.
Nursing care has always been a major part of in and out-patient management in most
morbidity cases, such as Cerebrovascular Disease like stroke. Having seen the increasing number
of CVD cases in our country, this has led to our interest in the study of CVD as a case. It is
through this case report that we can apply the appropriate nursing care through skills to alleviate
patients symptoms, and provide quality care.

OBJECTIVES
At the end of 30-minutes case presentation, student nurses will be able to:
Knowledge
-

Explain the pathophysiology of Cerebrovascular Disease.

Identify factors that contribute to the development of CVD.

Enumerate signs and symptoms of the disease.

Skills
-

Apply the Nursing Process in formulating appropriate nursing care plan for patient with
Cerebrovascular Disease.

Construct a realistic and timely manner plan of care to patient with cerebrovascular
disease.

Demonstrate competence in discussing the pathophysiology of the disease process.

Attitude
-

Maintain confidentiality on patients data.

Display professionalism in caring for a patient with CVA.

Internalize the value of care and understanding to a patient with CVA.

DEMOGRAPHIC DATA
Patient Mr. Strokesman, a 67 year old, male, married; Filipino; Seventh-Day Adventist;
born on June 15, 1949; a retired teacher, residing in San Juan Pontevedra Negros Occidental.
Admitted for the first time in Adventist Medical Center Bacolod, date September 4, 2016,
while due to slurred speech and left-sided weakness. His provisional diagnosis was: to consider
CVD Infarct, HCVD, DM II, and is finally diagnosed with Acute Infarct, Right Corona Radiata
by his attending physician, Dr. Reynold A. Wong. On September 13, 2016 at around 7:10 pm,
Mr. Strokesman was discharged.

NURSING HISTORY
History of Present Illness
Informant: Mr. Strokesman and his son
According to Mr. Strokesmans son, on September 4, 2016 early morning, Mr.
Strokesmans sat on his chair beside his bed after he woke up while he was inside his room, he
wanted to go outside so he stood up to open the door, but suddenly fell to the floor. His family
members heard a bang and immediately rush to it. They found the patient lying on the floor but is
conscious. According to his son, he didnt feel anything (e.g. dizziness, nauseated, etc.) before
his fall. But they noticed that he had slurring of speech and signs of weaknesses so they
immediately rushed him to CLMMRH, but because they werent given any attention, they
decided to transfer the patient to Adventist Medical Center-Bacolod. According to the patients
son, the patient was just feeling fine during the transportation, it them, the son and the other

members of the family who were panicking. They immediately brought him to Emergency
Department of AMC-B with a chief complaint of slurring of speech and left sided weakness.

History of Past Illness

On the year 2006, Mr. Strokesman underwent Appendectomy at Riverside Regional
Medical Center. In 2011, upon with a private medical doctor, he was diagnosed with
hypertension and Diabetes Mellitus type 2. Since then, the patient has regular check-up in the
nearest center, and with good compliance to Amlodipine, tab (10mg/tab) OD, for his
hypertension and Glimipiride, 1tab (2mg/tab) OD, for his Diabetes Mellitus type 2. The patient
has no known allergies to any food or drugs. According to the patients son, they were juicing his
father every morning ever since of his diagnosis of hypertension and DM II. The normal range of
the patients BP is 140/60 to 180/100 mmHg and the normal range of the patients RBS ranges
from 150 to 310 g/dL.

GORDONS HEALTH AND FUNCTIONAL ASSESSMENT

Health Perception Health Management
According to Mr. Strokesmans son, the patient is very compliant with his maintenance
medications: Amlodipine for his hypertension and Glimiperide for his Diabetes Mellitus. Finance
is considered as one of their major concerns in the health care of their patient.

Nutrition Metabolic Pattern

Mr. Strokesmanusually eats food rich in fats and cholesterol before he was diagnosed
with hypertension and DM type 2. After being diagnosed, he shifted his diet to a low fat diet but
at times eat fat-rich or cholesterol-rich foods such as meat and the like. He also loves to eat sweet
foods. The patient eats regularly, which is three times a day and doesnt skip his meals. The
patient doesnt smoke but he drinks alcohol occasionally, at least a bottle, when his friends would
invite him.
Elimination Pattern
Patient usually defecates three times a day, one in the morning and another in the
afternoon. According to his son, he experienced no difficulty in his elimination pattern. His stool
would often be soft but solid and brown in color. He also urinates depending on how much water
he takes in a day.
Activity Exercise Pattern
Since his retirement, Mr. Strokesman is a pensioner and usually stays at home to watch
over his grandchildren. He at times does the household chores when his wife or children are not
around. In the afternoon, if he has time, he would go out for a stroll for 15 to 20 minutes.
Cognitive Perceptual Pattern
According to Mr. Strokesmans son, before the presence of his present condition, the
patient was able to express his self clearly and logically. Ang obra niya lang na sa balay kay
permi gina akigan iya mga apo, basi amo pagid na gani ang rason nga natumba siya kay permi
lang siya gapa stress kag pangakig, as what Mr. Strokesmans son verbalized.

Sleep Rest Pattern

Mr. Strokesman usually sleeps at 10 oclock in the evening the most. He usually wakes
up at around 5 oclock in the morning. Upon waking up, he would help his wife or his children
with the cooking or preparation of foods. He may at times take naps in the afternoon for 20 30
minutes when his grandchildren are also taking their naps. The patients sleeping pattern was not
disturbed as he doesnt always experience nightmares. The patient always feels physically rested
and relaxed when he wakes up in the morning.
Role Relationship Pattern
Mr. Strokesman is a father of four and a grandfather of 8. He lives, together with his wife,
at the house of his youngest son and his family. The patient has a strong and close relationship
with his children and grandchildren.
Sexuality/Reproductive Pattern
The patient is satisfied with his current situation related to sexuality. He doesnt have any
diseases in his reproductive system.
Stress Tolerance and Coping Pattern
The patient experiences stress especially when his grandchildren are being hard-headed.
He would always scold them as his way of venting out his anger and stress. The patient copes
with his problems by talking with his wife and his children. According to his son, ang obra niya
lang na sa balay kay permi gina akigan iya mga apo, basi amo pagid na gani ang rason nga
natumba siya kay permi lang siya gapa stress kag pangakig.

Values and Beliefs

The patient is a Seventh-Day Adventist and goes to church on Saturday if he wants to and
also believes in God.

FAMILY GENOGRAM
Fathers Side
U

Mothers Side

70

64

89

59

59

66

HTN

VA

HTN

67
HTN & DM
Acute Infarct, Right
Corona Radiata

64

63

60

HTN

LEGEND:

Male

HPN

Hypertension

Female

DM

Diabetes Mellitus type 2

Deceased

Unknown

Age

VA

Vehicular Accident

68

52

75

76

80]

DM

HPN

27
VA

10

CHAPTER II
THE DISEASE ENTITY
This chapter contains the chief complaint and the medical diagnosis of the patient, the
anatomy and physiology of the brain, and the pathophysiology of the disease.
Chief Complaint: Slurred speech and left-sided body weakness
Medical Diagnosis: Acute Infarct, Right Corona Radiata

ANATOMY AND PHYSIOLOGY

Central Nervous System
The Central Nervous System (CNS) is composed of the brain and spinal cord. The
CNS is surrounded by bone-skull and vertebrae. Fluid and tissue also insulate the brain and
spinal cord.
Areas of the Brain
The brain is composed of three parts: the cerebrum (seat of consciousness), the
cerebellum, and the medulla oblongata (these latter two are part of the unconscious brain). The
medulla oblongata is closest to the spinal cord and is involved with the regulation of heartbeat,
breathing, vasoconstriction (blood pressure), and reflex centers for vomiting, coughing, sneezing,
swallowing and hiccupping. The hypothalamus regulates homeostasis. It has regulatory areas for
thirst, hunger, body temperature, water balance and blood pressure and links the nervous system

11

to the Endocrine System. The midbrain and pons are also part of the unconscious brain. The
thalamus serves as a central relay point for incoming nervous messages.
The cerebellum is the second largest part of the brain, after the cerebrum. It functions for
muscle coordination and maintains normal muscle tone and posture. The cerebellum coordinates
balance.
The conscious brain includes cerebral hemispheres, which are separated by the corpus
callosum. In reptiles, birds, and mammals, the cerebrum coordinates sensory data and motor
functions. The cerebrum governs intelligence and reasoning, learning and memory. While the
cause of memory is not yet definitely known, studies on slugs indicate learning is accompanied
by a synapse decrease. Within the cell, learning involves change in gene regulation and increased
ability to secrete transmitters.
The Brain
During embryonic development, the brain first forms a tube, the anterior end which
enlarges into three hollow swellings that form the brain, and the posterior of which develops into
spinal cord. Some parts of the brain have changed little during vertebrate evolutionary history.
Parts of the Brain as seen from the Middle of the Brain
Vertebrate evolutionary trends include:
1. Increase in brain size relative to body size.
2. Subdivision and increasing specialization of the forebrain, midbrain and hindbrain.
3. Growth is relative in size of the fore brain, especially the cerebrum, which is
associated with increasingly complex behavior in mammals.

12

The Brain Stem and Midbrain

The brain stem is the smallest and from an evolutionary viewpoint, the oldest and most
primitive part of the brain. The brain stem is continuous with the spinal cord, and is composed of
the parts of the hindbrain and midbrain. The medulla oblongata and pons control heart rate,
constriction of blood vessels, digestion and respiration. The midbrain consists of connections
between the hindbrain and forebrain. Mammals use this part of the brain only for eye reflexes.
The Cerebellum
The cerebellum is the third part of the hindbrain, but it is not considered part of the brain
stem. Functions of the cerebellum include fine motor coordination and body movement, posture
and balance. This region of the brain is enlarged in birds and controls muscle action needed for
flight.
The Forebrain
The forebrain consists of the diencephalon and cerebrum. The thalamus and
hypothalamus are parts of the diencephalon. The thalamus acts as a switching center for nerve
messages. The hypothalamus is a major homeostatic center having both nervous and endocrine
functions.
The Cerebrum
The cerebrum, the largest part of the human brain, is divided into left and right
hemispheres connected to each other by the corpus callosum. The hemispheres are covered by a
thin layer of gray matter known as the cerebral cortex, amphibians and reptiles have only
rudiments of this area.

13

The cortex in each hemisphere of the cerebrum is between 1and 4mm thick. Folds divide
the cortex into four lobes: occipital, temporal, parietal, and frontal. No region of the brain
functions alone, although major functions of various parts of the lobes have been determined.
The occipital lobe (back of the head) receives and processes visual information. The
temporal lobe receives auditory signals, processing language and the meaning of words. The
parietal lobe is associated with the sensory cortex and processes information about touch, taste,
pressure, pain, and heat and cold. The frontal lobe conducts three functions:
1. Motor activity and integration of muscle activity
2. Speech
3. Thought processes
Most people who have been studied have their language and speech areas on the left
hemisphere of their brain. Language comprehension is found in Wernickes area. Speaking
ability is in Brocas area. Damage to Brocas area causes speech impairment but not impairment
of language comprehension. Lesions in Wernickes area impair ability to comprehend written and
spoken words but not speech. The remaining parts of the cortex are associated with higher
thought processes, planning, memory, personality and other human activities.

14

Clinical Pathway Presentation

Predisposing Factors:
-

Precipitating Factors:

Age: 67 years old

Gender: Male
Hypertension (2011)
DM type II (2011)

Tx:

- Atorvastatin
Narrowing of blood
vessels (Coronary Artery)

Decreased blood flow

through coronary artery

Decreased blood to the

heart
Sx:
BP: 160/90
mm Hg

Increased fat deposit on

the walls of the blood
vessel.

Sedentary Lifestyle
Diet (High Fat,
Cholesterol)

Insufficient insulin
secretion/production of the
pancreas

Atherosclerosis

Increased pressure on the

walls of blood vessels

Increased peripheral
vascular resistance

Glucose is not metabolized

by the body

Increased viscosity of
blood

Slugging flow of blood

Increased blood pressure

Some fragments joins in

circulation (embolism)
Increased concentration of
sugar in the blood

HCVD

Severe elevation in BP
without progressive target
organ
Sx:
BP
Monitoring:
160/60
170/90
mmHg

Hypertension

Travels & clogs small

vessels (deep penetrating
arteries especially lacunar
area/corona radiate area)

Obstruction/interruption of
O2 supply due to
decreased blood supply

Dx:
RBS
Monitoring: 54
214 mg/dL

Tx:
- Glimiperide
- Humulin R

Sx:
- Increased thirst
- Fatigue
- Slow-healing sores

15

If treated:

- Nursing management
- Diet management
- Pharmacologic
medications
- O2 therapy

Recovery

Tx:
- Losartan+Amlodipine
- Amlodipine
- Nitroglycerine

If untreated:

Further complication
can occur:
- Ischemia
- Angina Pectoris
- MI

Lacunar infarct / Corona

Radiata Infarct

Decreased O2 supply to
Basal Ganglia,

INFARCTION

Influences Autonomic Nervous

System
(Responsible for cerebellar
functions)

Affects motor skills

Death
Sx:
- Slurring of Speech
(Dysphasia)
- Dysphagia
- Left sided weakness

16

CHAPTER III
THE MANAGEMENT
This chapter contains the nursing physical assessment, diagnostic studies results and
significance, drug study, nursing care plan, and the discharge summary.

NURSING PHYSICAL ASSESSMENT

General Overall Health State
Our patient is a 76-year old, male, who was admitted with the chief complaint of slurring
of speech and left sided weakness and was diagnosed with Acute Infarct, Right Corona Radiata.
The patient is asleep, has no bathroom privileges and needs assistance in turning and with his
ADLs. Mr. Strokesman has a Braden Scale of 16 and a GCS of 14, with cardiac monitor and
pulse oximetry attached. His vital signs upon assessment were: Temp: 36.3C, PR: 78 bpm, RR:
16 cpm, BP: 170/90 mmHg, and O2 Sat: 99%.
Skin
The patients skin is warm with good skin turgor and with fair complexion. No
abnormalities observed. No noted cyanosis or clubbing of nails on the patient on both hands and
feet. Capillary refill is 1 second.
HEENT
Head is symmetrical and no lesions noted on the patients head. Patients pupils are
equally round and reactive to light and accommodation. The sclera is clear and the conjunctivas

17

are pinkish in color in both eyes. Ears are symmetrical in shape and no lesions or discharges
observed. Nose is symmetrical in shape, presence of NGT tube at the left nostril, no presence of
discharges observed. No tenderness noted upon palpation on the frontal and maxillary sinuses.
Lips appear to be slightly dry.
Neck
No masses found upon inspection and palpation of cervical lymph nodes. No distension
of jugular vein noted and no unusual pulsations upon inspection. No deviations of trachea noted
upon palpation. No irregularities of the thyroid gland noted upon inspection and palpation.
Respiratory System
Respiratory rate of patient upon assessment is 18 cpm. Patient is with nasal cannula, O2
running at 2L/min. Stridor is heard upon inspection and observation of the patients breathing.
Cardiovascular System
Heart rate of patient upon assessment is 97 bpm. No unusual pulsation observed on the
patients jugular vein. No abnormal heart sounds heard upon auscultations.
Gastrointestinal and Urinary System
Patient is with NGT and urinary catheter. No tenderness observed upon palpation of the
abdominal area and no unusualities heard, such as hyperactive bowel sounds, upon auscultation
of the patients abdomen.

18

Neurologic System
Upon assessment, patient was oriented to time, person, and place. Appropriate thought
process is observed by being able to answer questions appropriately, although some words are
hard to make out due to the patients slurring of speech; patient readily answers when asked with
some questions. Patient is able to recall what happened before and after he fell down, and
memories way before his accident. Patient is friendly to the staffs and socializes with them. The
patient has minimal left-sided weakness and is able to move his left arm and left leg with a
limited range of motion. The patients right arm and legs is with full range of motion. Pain reacts
upon pain infliction by jolting or moving away from the source of pain.
Endocrine System
Patient was diagnosed with Diabetes Mellitus type 2 on the year 2011, upon consultation
to a private medical doctor.

19

Diagnostic Studies Results and Significance

Clinical Chemistry Section
Result

K (Potassium)

September 12, 2016 5:20 AM

Normal Value
Significance
Decrease in
potassium levels

3.18 mmol/L (L)

3.50 5.10 mmol/L

September 7, 2016 6:10 AM

(L)

may indicate
dehydration, stress,
diabetic acidosis,
excessive ingestion

K (Potassium)

2.87 mmol/L (L)

Result

of glucose.
September 13, 2016 5:17 AM
Normal Value
Significance
Increased glucose
level may indicate

RBS Glucometer

116 mg/dL

60 110 mg/dL

presence of
Diabetes Mellitus,

or excessive stress.
September 12, 2016 5:15 PM
Decreased glucose
level may indicate
RBS Glucometer

54 mg/dL

60 110 mg/dL

insulin overdose or
rebound
hypoglycemia.

September 9, 2016 2:00 PM

RBS Glucometer

September 6, 2016 6:20 PM

RBS Glucometer

FBS (Glucose)

Increased in glucose

214 mg/dL

levels may indicate

60 110 mg/dL

Diabetes Mellitus,

149 mg/dL

Result
129 mg/dL (H)

presence of

or excessive stress.
September 5, 2016 6:30 AM
Normal Value
Significance
74.00 106.00
Increased glucose
mg/dL (H)

level indicates the

20

presence of
Diabetes Mellitus

Hematology Section
Result
HCT

0.34

September 12, 2016 6:20 AM

CBC + PLT
Normal Value
Significance
Decreased hematocrit levels
0.40 0.52

LYMP%

0.10

0.25 0.35

EO%

0.12

0.01 0.03

indicates anemia due to certain oral

diabetes drugs, or malnutrition.
Decreased levels indicate the
presence of a chronic infection.
Elevation of the eosinophil count
may indicate an increase in the
bacterial, viral, parasitic, or allergic
conditions, and also anemia.
Increased levels may indicate

POLYS

0.71

Result
HCT

0.34

0.05 0.65

presence of acute bacterial

infections or inflammations.
September 7, 2016 7:00 AM
Normal Value
Significance
Decreased hematocrit levels
0.37 0.47

indicates anemia due to certain oral

diabetes drugs, or malnutrition.
Decreased RBC levels may

RBC

3.90

46

indicate presence of anemia or

malnutrition.
Slight elevations of the WBC count

WBC

10.14

5 10

LYMP%

0.07

0.25 0.35

EO%

0.05

0.01 0.03

may indicate infections, bacterial

or viral occurrence in response to
chronic infections.
Decreased levels indicate the
presence of a chronic infection.
Elevation of the eosinophil count
may indicate an increase in the
bacterial, viral, parasitic, or allergic

21

conditions, and also anemia.

Increased levels may indicate
POLYS

MCH

0.81

31.30

Chest X Ray

0.05 0.65

26 31

presence of acute bacterial

infections or inflammations.
Slight elevation may be due to
decreased amount of hemoglobin.

September 5, 2016

Impression:
Clear lungs
True cardiac size not ascertained
Atherosclerotic aorta

CT Scan Result (Brain, Plain)

September 9, 2016
Impression:
- Probable acute infarct, right side of the pons
- Multiple small infarcts, right cerebellum, right lentiforms nucleus, right external
-

capsule & right corona radiata

Ischemia changes, both corona radiate & both centrum semi ovale
Arteriosclerotic vertebral and internal carotid arteries
Bilateral ethmoid& left frontal sinusitis

22

Drug Study
PARENTERAL MEDS
Generic/Brand Name:Citicoline Sodium /

Classification: CNS Stimulants

Zynapse
Dosage/Route: 1g q8
Indication: Citicoline is indicated in CVD in acute recovery phase in severe s/sx of
cerebrovascular insufficiency and in-cranial traumatism and their sequallae. Citicoline in CVA,
stimulates brain function.
Mechanism of Action: Citicoline increases blood flow and O2 consumption in the brain. It is
also involved in the biosynthesis action.
Side Effects/Adverse Reactions: Fleeting and discrete hypotension effect, increased
parasympathetic effects, low blood pressure, itching or hives, swelling in face or hands, chest
tightness, tingling in mouth and throat.
Nursing Consideration: - Monitor for adverse effect.
- Monitor patients neurologic status.
- Note presence of slurring in speech.
Patient Teaching: - Instruct patient to take the medication as prescribed.
-

Teach the patient that citicoline may be taken with or without food.
Instruct patient to report immediate feelings of chest tightness, tingling
in mouth and throat, headache, diarrhea and blurring of vision.

Generic/Brand Name:Ampicilin Sodium and

Classification: Antibiotic Aminopenicillin

Sulbactam Sodium / Unasyn

and beta-lactamase inhibitor
Dosage/Route: 750mg ANST (-) q8 IVTT
Indication: Indicated for the treatment of intra-abdominal infections, pneumonia, soft tissue
infections, sinusitis, septicemia.
Mechanism of Action: Interferes with cell wall replication of susceptible organisms. Destroys
bacteria by inhibiting bacterial cell-wall synthesis during microbial multiplication. Addition of
sulbactam enhances drugs resistance to beta-lactamase, an enzyme that can inactivate
ampicillin.
Side Effects/Adverse Reactions: CNS: Lethargy, hallucinations, anxiety, confusion, agitation,
depression, fatigue, dizziness, seizure. EENT: blurred vision, itchy eyes. GI: nausea, vomiting,
diarrhea, abdominal pain, gastritis, stomatitis. GU: hematuria, hyaline cast in urine, vaginitis,
nephropathy, interstitial nephritis. RESPIRATORY: wheezing, dyspnea, hypoxia, apnea. SKIN:

23

rash, urticarial, diaphoresis.

Nursing Consideration: - Assess patient of previous sensitivity reaction to penicillin or
cephalosporins.
-

Assess patient for signs and symptoms of infections or

superinfections.
- Assess for allergic reactions.
- Monitor blood studies.
- Monitor electrolytes.
- Assess bowel pattern daily.
- Monitor for bleeding.
Patient Teaching: - Instruct patient to report rash, fever, or chills. A rash is the most common
allergic reaction.

ORAL MEDS
Generic/Brand Name: Atorvastatin Calcium /

Classification: Antihyperlipidemic HMG-

Lipitor
CoA reductase inhibitor
Dosage/Route: 40mg/tab ODHS P.O.
Indication: Prevention of CV disease in adults without clinically evident coronary disease but
with multiple risk factors for CAD such as age >55 yr, smoking, hypertension, low HDL-C,
family history of early CAD; to reduce the risk of MI and risk for revascularization procedures
and angina.
Mechanism of Action: Inhibits HMG-CoA reductase, the enzyme that catalyzes the first step
in the cholesterol synthesis pathway, resulting in a decrease in serum cholesterol, serum LDLs
(associated with increased risk of CAD), and increases serum HDLs (associated with
decreased risk of CAD); increases hepatic LDL recapture sites, enhances reuptake and
catabolism of LDL; low triglyceride levels.
Side Effects/Adverse Reactions: CNS: Headache, asthenia
GI: flatulence, abdominal pain, cramps, constipation,
nausea, dyspepsia, heartburn, liver failure
RESPIRATORY: sinusitis, pharyngitis
Other: rhabdomyolysis with acute renal failure, arthralgia,
myalgia
Nursing Consideration: Assessment
-

History: Allergy to atorvastatin, fungal byproducts; active hepatic

24

disease; acute serious illness; pregnancy, lactation

Physical: Orientation, affect, muscle strength; liver evaluation,
abdominal examination; lipid studies, LFTs, renal function tests

Intervention
-

Obtain LFTs as a baseline and periodically during therapy;

discontinue drug if AST and ALT levels increases to 3 times

normal levels
Withhold atorvastatin in any acute, serious condition (severe
infection, hypotension, major surgery, trauma, severe metabolic or
endocrine disorder, seizures) that may suggest myopathy or serve

as risk factor for development of renal failure.

Patient Teaching: - Inform patient about side effects of drug such as nausea (eat frequent
small meals); headache, muscle and joint aches and pains (may lessen
over time)
-

Advise patient to report presence or feelings of muscle pain, weakness,

tenderness; malaise; fever, changes in color of urine or stool; swelling.

Generic/Brand Name:Glimiperide / Amaryl

Classification: Antidiabetic - Sulfonylurea
Dosage/Route: 2mg/tab OD P.O.
Indication: Glimiperide is indicated to treat DM type 2 in patients with uncontrolled blood
sugar levels.
Mechanism of Action: Lowers glucose levels by stimulating pancreas to release insulin.
Side Effects/Adverse Reactions: CNS: dizziness, asthenia, headache
EENT: changes in accommodation
GI: nausea
Hematologic: leukopenia, haemolytic anemia,
agranulocytosis, thrombocytopenia, aplastic anemia,
pancytopenia
Metabolic: hypoglycaemia, dilutionalhyponatremia
Nursing Consideration: - Glimiperide and insulin may be given together in patients who lose
glucose control after first responding to therapy.
- Monitor fasting glucose level periodically to determine therapeutic response. Also

25

monitor glycosylated haemoglobin level, usually every 3 to 6 months, to precisely

assess long-term glycemic control.
Patient Teaching: - Make sure that the patient understands that therapy relieves symptoms but
doesnt cure the disease. Patient should also understand potential risks and
advantages of taking drug and of other treatment methods.
-

Stress importance of adhering to diet, weight reduction, exercise, and

personal hygiene programs. Explain to patient and family how and when
to monitor glucose level, and teach recognition of and intervention for

signs and symptoms of high and low glucose levels.

Educate patient to carry candy or other simple sugars to treat mild
episodes of low glucose level.

Generic/Brand Name:Losartan+Amlodipine /

Classification: Calcium Antagonists /

Tozam
Angiotensin II Antagonists
Dosage/Route: 500mg/5mg 1tab BID (Hold for BP <130mmHg) P.O.
Indication: Indicated to treat mild to moderate hypertension.
Mechanism of Action: Amlodipine inhibits the movement of Ca ions across the cell
membrane into vascular smooth muscles and myocytes. Losartan is an angiotensin II receptor
(type AT1) antagonists antihypertensive which acts by blocking the actions of angiotensin II of
renin-angiotensin-aldosterone system.
Side Effects/Adverse Reactions: Headache, dizziness, back pain, myalgia, respiratory tract
disorders, asthenia/fatigue; first-dose hypotension, rash, cough, angioedema; neutropaenial GI
disturbances; transient elevation of liver enzymes; taste disturbances and hyperkalemia,
hypotension, bradycardia, conductive system delay, CCF.
Nursing Consideration: - Monitor blood pressure frequently during initiation of therapy.
Because drug-induced vasodilation has a gradual onset, acute
hypotension is rare.
-

Notify prescriber if signs of heart failure occur, such as swelling of

hands and feet or shortness of breath

Monitor patient closely if also taking diuretics for symptomatic

26

hypotension
- Regularly assess the patients renal function
Patient Teaching: - Advise patient to avoid salt substitutes; these products may contain
potassium, which can cause high potassium level
-

Advise patient to immediately report swelling of face, eyes, lips, or tongue

or any breathing difficulty

Generic/Brand Name:Acetylcysteine /

Classification: Mucolytic L-cysteine

Exflem
derivative
Dosage/Route: 600mg 1tab BID 500cc H2O P.O.
Indication: Adjunct therapy for abnormal viscid thickened mucous secretions in patients with
pneumonia, bronchitis, bronchiectasis, primary amyloidosis of the lung, tuberculosis, cystic
fibrosis, emphysema, atelectasis, pulmonary complications of thoracic surgery, or CV surgery.
Mechanism of Action: Reduces the viscosity of pulmonary secretions by splitting disulphide
linakages between mucoprotein molecular complexes. Also, restores liver stores of glutathione
to treat acetaminophen toxicity.
Side Effects/Adverse Reactions: CNS: abnormal thinking, fever, drowsiness, gait
disturbances
CV: chest tightness, flushing, hypertension, hypotension,
tachycardia
EENT: rhinorrhea, ear pain, eye pain, pharyngitis, throat
tightness
GI: nausea, stomatitis, vomiting
Respiratory: bronchospasm, cough, dyspnea, rhonchi
Skin: clamminess, diaphoresis, pruritus, rash, urticarial
Other: anaphylactoid reaction, angioedema, chills
Nursing Consideration: - Monitor cough type and frequency
-

Monitor patient for bronchospasm

Ingestion of more than 150mg/kg of acetaminophen may cause
liver toxicity. Measure acetaminophen level 4 hours after ingestion

to determine risk of liver toxicity.

Patient Teaching: - Warn patient that drug may have a foul taste or smell that may be
distressing

27

Generic/Brand Name: Lactulose / Lilac

Classification: Laxative Dissacharide
Dosage/Route: 30cc BID P.O.
Indication: Lactulose is indicated to prevent or treat constipation
Mechanism of Action: Produces an osmotic effect in colon; resulting distention promotes
peristalsis. Also decreases ammonia, probably as a result of bacterial degeneration, which
lowers the pH of colon contents.
Side Effects/Adverse Reactions: GI: abdominal cramps, belching, diarrhea, flatulence,
gaseous distention, nausea, vomiting
Nursing Consideration: - Monitor sodium level for hypernatremia, especially when giving in
higher doses
- Monitor mental status and potassium levels
- Replace fluid loss
Patient Teaching: - Inform patient about adverse reactions and tell him to notify prescriber if
reactions become bothersome or if diarrhea occurs
-

Instruct patient not to take other laxatives during lactulose therapy

Generic/Brand Name: Pregabalin / Funxion

Classification: Anticonvulsant CNS drug
Dosage/Route: 500mg/cap 1cap ODHS P.O.
Indication:Pregabalin is indicated to treat diabetic peripheral neuropathy
Mechanism of Action: May contribute to analgesic and anticonvulsant effects by binding sites
in CNS.
Side Effects/Adverse Reactions: CNS: ataxia, somnolence, tremor, abnormal gait, asthenia,
vertigo, nystagmus, euphoria
CV: edema, PR interval prolongation
EENT: blurred or abnormal vision, eye disorder
GI: dry mouth, abdominal pain, gastroenteritis
GU: anorgasmia, impotence, urinary incontinence
Metabolic: hypoglycaemia, weight gain
Musculoskeletal: arthralgia, myalgia, myasthenia
Respiratory: bronchitis, dyspnea
Skin: ecchymosis, pruritus
Nursing Consideration: - Monitor patient for signs and symptoms of angioedema which may
compromise breathing
-

Monitor patients weight and fluid status

Check for changes in vision

28

Watch for signs of rhabdomyolysis, such as dark, red, or colacolored urine; muscle tenderness; generalized weakness; or muscle

stiffness or aching
Patient Teaching: - Caution patient to avoid hazardous activities until drugs effects are
known.
-

Instruct patient to watch for weight changes and water retention.

Advise patient to report vision changes and malaise or fever accompanied

by muscle pain, tenderness, or weakness

If patient has diabetes, urge him to inspect his skin closely for ulcer
formation

Generic/Brand Name: Clipidogrel bisulfate /

Classification: Antiplatelet Platelet

Platexan
aggregation inhibitor
Dosage/Route: 75mg/tab OD P.O.
Indication: Indicated to reduce thrombotic events in patients with atherosclerosis documented
by recent stroke, MI, or peripheral arterial disease
Mechanism of Action: Inhibits the binding of adenosine diphosphate (ADP) to its platelet
receptor, impending ADP-mediated activation and subsequent platelet aggregation, and
irreversibly modifies the platelet ADP receptor.
Side Effects/Adverse Reactions: CNS: confusion, fatal intracranial bleeding, hallucinations
CV: hypotension
EENT: epistaxis, rhinitis, taste disorder
GI: haemorrhage, abdominal pain, constipation, diarrhea,
dyspepsia, gastritis, ulcers
GU: UTI, hematuria
Hematologic: purpura
Musculoskeletal: arthralgia, myalgia, arthritis
Respiratory: bronchospasm, respiratory tract bleeding
Skin: rash, pruritus, eczema, Stevens-Johnson syndrome
Nursing Consideration: - Drug may cause fatal thrombotic thrombocytopenic purpura that
requires urgent treatment, including plasmapheresis
Patient Teaching: - Advise patient it may take longer than usual to stop bleeding. Advise him
to refrain from activities in which trauma and bleeding may occur, and
encourage him to wear a seat belt when in a car.

29

Instruct patient to notify prescriber if unusual bleeding or bruising

occurs.
Tell patient to inform all health care providers, including dentists, before
undergoing procedures or starting new drug therapy, that he is taking
drug.

Generic/Brand Name: Piracetam / Nootropil

Classification: Neuromuscular agent
Dosage/Route: 1.2g/tab BID PO
Indication: Piracetam
Mechanism of Action: Piracetam acts selectively upon telencephalon by improving its
associative function. It increases the energy output of the brain cell and activates its
neurophysiological potentialities, especially in deficit conditions. Nootropil is virtually
nontoxic and has a stimulating, sedative or neurovegetative activities.
Side Effects/Adverse Reactions: Hyperkinesia, weight gain, asthenia, nervousness, agitation,
irritability, anxiety and sleep disturbance, fatigue or drowsiness, GI disturbances
Nursing Consideration: - Monitor heart rate, ECG and BP periodically throughout the
therapy
-

Drug has strong taste. Mixing oral form with orange juice mask

the taste
- Assess patients airway
- Provide support ventilation, if needed
- Assess and support cardiac function
Patient Teaching: - Advise patient to report any unusualities

Generic/Brand Name: Potassium Chloride

Classification: Potassium supplement
Dosage/Route: 20mL TID x 6 doses P.O.
Indication: Potassium chloride is indicated to prevent and treat hypokalemia
Mechanism of Action: Replaces potassium and maintain potassium level
Side Effects/Adverse Reactions: CNS: paresthesia of limbs, confusion, flaccid paralysis
CV: arrhythmias, heart block, cardiac arrest, hypotension
GI: nausea, vomiting, abdominal pain, diarrhea
Metabolic: hyperkalemia
Respiratory: respiratory paralysis
Nursing Consideration:- Patients at an increased risk of GI lesions include those with
scleroderma, diabetes, mitral valve replacement, cardiomegaly, or

30

esophageal strictures, and elderly or immobile patients

-

Drug is commonly used orally with potassium-wasting diuretics to

maintain potassium levels

- Monitor ECG and electrolyte levels during therapy
- Monitor renal function
- Many adverse reactions may reflect hyperkalemia
Patient Teaching: -Teach patient how to prepare powders and how to take drug. Tell patient to
take with or after meals with full glass of water or fruit juice to lessen GI
lesions
-

Educate patient of the signs and symptoms of hyperkalemia, and instruct

patient to notify prescriber if they occur

Warn patient not to use salt substitutes concurrently, except with
prescribers permission

Generic/Brand Name: Amlodipinebesylate

Classification: Antihypertensive Calcium

(Provasc)
Channel Blocker
Dosage/Route: 10 mg/tab tab OD P.O.
Indication: Indicated to treat hypertension and prevent chronic stable angina or vasospastic
angina
Mechanism of Action: Inhibits the movement of calcium ions across the membrane of cardiac
and arterial muscle cells, slowing the conduction of the cardiac impulse, and decrease cardiac
work, decrease cardiac oxygen consumption and increases on to cardiac cells.
Side Effects/Adverse Reactions: CNS: fatigue, dizziness, light-headedness, asthenia
CV: edema, flushing, palpitations
GI: dyspepsia, nausea, abdominal pain
GU: sexual difficulties
Musculoskeletal: muscle cramps
Respiratory: dyspnea
Skin: rash, pruritus
Nursing Consideration:- Monitor blood pressure frequently during initiation of therapy.
Because drug-induced vasodilation has a gradual onset, acute
hypotension is rare.
-

Notify prescriber if signs of heart failure occur, such as swelling of

hands and feet or shortness of breath

31

Abrupt withdrawal of drug may increase frequency and duration of

chest pain. Taper dose gradually under medical supervision

Patient Teaching: -Caution patient to continue taking drug, even when he feels better
-

Educate patient that nitroglycerin may be taken as needed when angina

symptoms are acute. If patient continues nitrate therapy during
adjustment of amlodipine dosage, urge continued compliance

TREATMENT MEDS
Generic/Brand Name: Nitroglycerine (NTG

Classification:Vasodilator - Nitrate

Patch)
Dosage/Route: 5mg OD ACW
Indication: Nitroglycerine is indicated in preventing chronic angina attacks and hypertension
Mechanism of Action: Relaxes (widens) blood vessels to allow blood to flow more easily.
This reduces the heart's workload and the amount of oxygen needed by the heart.
Side Effects/Adverse Reactions: CNS: dizziness, syncope, weakness
CV: orthostatic hypotension, tachycardia, palpitations
EENT: S.L. burning
GI: nausea, vomiting
Skin: cutaneous vasodilation, contact dermatitis, rash
Nursing Consideration: - Administer nitroglycerin patch with extreme caution to patients
with hypotension or hypovolemia since the drug may precipitate a
severe hypotensive state.
-

Closely monitor vital signs, particularly blood pressure. Excessive

hypotension can worsen ischemia

Patient Teaching: - Urge patient using skin patches to dispose of them carefully because
enough medication remains after normal use to be hazardous to children
and pets
-

Advise patient to avoid alcohol while on therapy

To minimize dizziness when standing up, tell patient to rise slowly.
Advise patient to go up and down stair carefully and to lie down at the
first sign of dizziness

STAT MEDS

32

Generic/Brand Name:Insulin(HumulinR)

Classification:Antidiabetic Pancreatic

hormone
Dosage/Route: 5 units/mLSubq
Indication: Treatment of type 1 (insulin-dependent)diabetesand type 2 (non- insulindependent) diabetes
Mechanism of Action: Insulin is a hormone secreted by the beta cells of the pancreas that, by
receptor-mediated effects, promotes the storage of the body's fuels, facilitating the transport
of metabolites and ions (potassium)through cell membranes and stimulating the synthesis
of glycogen from glucose, of fats from lipids, and proteins from amino acids.
Side Effects/Adverse Reactions: EENT: blurred vision
GI: dry mouth
Metabolic: hypoglycaemia, hyperglycemia,
hypomagnesemia, hypokalemia
Skin: rash, urticaria, pruritus, swelling, redness, stinging,
warmth at injection site
Respiratory: increased cough, respiratory tract infection,
dyspnea, reduced pulmonary function
Other: lipoatrophy, lipohypertrophy, anaphylaxis,
hyspersensitivity reactions
Nursing Consideration:- Monitor patient for hyperglycemia (rebound, or Somogyi, effect)
Patient Teaching: - Make sure that the patient knows that drug relieves symptoms but doesnt
cure the disease
-

Educate patient about the disease and importance of following

therapeutic regimen, adhering to specific diet, losing weight, getting
exercise, following personal hygiene program, and avoiding infection.
Emphasize importance of timing injections with eating and of not

skipping meals
Advise patient not to smoke within 30 minutes after insulin injection

because smoking decreases amount of insulin absorbed subcutaneously

Advise patient to avoid vigorous exercise immediately after insulin
injection, especially of the area where injection was given, because it

increases absorption and risk of low glucose episodes.

Advise patient to avoid alcohol because it lowers glucose levels.

33

Nursing Care Plan

Risk for aspiration related to presence of NGT
Cues: (Objectives):The patient is with NGT on left nostril, left sided weakness noted, slurring of speech, GCS 15 and CT scan
impression of probable acute infarct on the right side of the pons.
Expected Outcome: After 2 to 3 days of duty in the ICU, the patient will be able to successfully avoid aspiration.
Nursing Interventions (OME)
Rationale
1. Observed for signs associated with swallowing problems These are signs of swallowing impairment.
(difficulty handling oral secretions, wet or gurgly voice,
decrease ability to move tongue and lips).
2. Positioned client upright at 90 angle with the head of the

Maintaining a sitting position after meal may help decrease aspiration

bed when feeding and maintain 30-45 degrees afterward.

pneumonia in the elderly. Keeping clients head elevated helps keep

3. Maintained nasogastric tube securely tapes.

4. Determined placement of feeding tube before each

food in stomach and decreases incidence of aspiration.

Increases the length of time a tube stays taped.
Generally predicts position in the gastrointestinal tract, especially if

feeding. Auscultate patency, check residual and note

combined with identification of appearance of aspirate.

characteristics appearance.
5. Gave due OTF q3 100cc.

May be necessary for fluid replacement and nutrition if patient is

6. Educated client, and family, how to monitor client and

unable to take anything orally

Decreased chance of developing aspiration pneumonia.

prevent aspiration during feeding.

Evaluation: Goal met. After 3 days of duty, the patient did not undergo any incidence of aspiration.
References: Valenti, L., Rozinski, M., &Tamblyn, R. (1998). Lippincotts Review Series: Critical Care Nursing. Lippincott
Williams and Wilkins: Philadephia
Doenges, M., Moorehouse, M., &Murr, A. (2008). Nurses Pocket Guide: Diagnoses, Prioritized Interventions, and
Rationales. iGroup Press Co., Ltd.: Thailand

34

Ineffective cerebral tissue perfusion related to interruption of blood flow secondary to multiple small old infarcts as
manifested by changes in motor and language deficit
Cues (Objectives): The patient has left sided weakness and slurred speech noted, BP of 160/80, and patient is on bed rest. GCS of
15, CT scan impression of probable acute infarct on the right side of the pons.
Expected Outcome: After 3 days of nursing intervention, the patient will be able to demonstrate stable vital signs of BP- 140/80,
and maintain GCS of 15.
Nursing Interventions
1. Assess higher functions, including speech, alertness, and

Rationale
Changes in cognition and speech content are an indicator of location

assess for verbal impairment.

2.Monitor and document neurological status frequently and

and degree of cerebral involvement.

Assess trends in LOC as it is useful in determining location, extent,

compare with baseline

3. Evaluate pupils noting size, shape, equality, and light

and progression of CNS damage.

Pupil reactions are regulated by the oculomotor (III) cranial Nerve

reactivity.

and are useful in determining whether the brainstem in intact.

Response to light reflects combined function of the optic (II) and

4. Strictly monitor vital signs every 30 minutes to 1 hour.

oculomotor (III) cranial nerve.

Fluctuations in pressure may occur because of cerebral pressure or
injury in vasomotor area of the brain. Hypertension or hypotension

5. Position patients bed slightly elevated and in neutral

may have been a precipitating factor.

Reduces atrial pressure by promoting venous drainage and may

position.
6. Maintain bedrest, provide quiet environment, and restrict

improve cerebral circulation and perfusion.

Continual stimulation can increase ICP. Absolute rest and a quiet

visitors and activities as indicated. Provide rest periods

environmentmay be needed to prevent recurrence of infarction.

between care activities, limiting duration of procedures or

35

organize time of intervention.

7. Prevent straining at stool or holding of breath.

Activities that require holding the breath and bearing down( Valsalva
maneuver) can result in bradycardia (temporarily reduced cardiac

8. Administer supplemental oxygen as indicated.

9.Administer medications as indicated (e.g. anticoagulant,

output) and rebound tachycardia with elevated BP.

Reduces hypoxemia.
Hypertension requires cautious treatment because aggressive

and laxatives)
10.Monitor laboratories studies as indicated

management increases the damage during an evolving stroke.

Provides information about effectiveness and therapeutic level of

anticoagulant.
Evaluation: Goal Partially met. The patient still manifest unstable vital signs of 140/60, 150/70, 150/80, 160/80. Patients GCS
assessment is still 15 with noted slurring of speech and left sided weakness.
References: Valenti, L., Rozinski, M., &Tamblyn, R. (1998). Lippincotts Review Series: Critical Care Nursing. Lippincott
Williams and Wilkins: Philadephia
Doenges, M., Moorehouse, M., &Murr, A. (2008). Nurses Pocket Guide: Diagnoses, Prioritized Interventions, and
Rationales. iGroup Press Co., Ltd.: Thailand
Potawan, H.B. (2012, November). Ineffective Cerebral Tissue Perfusion. Retrieved October 4, 2016, from Scribd:
https://www.scribd.com/doc/114128541/Ineffective-Cerebral-Tissue-Perfusion

Activity intolerance related to left body weakness as evidenced by decreased muscle strength.
Cues (Objectives): The patient is on complete bed rest, with left side weakness, without bathroom privileges, Braden Scale is 16, of
BP-160/80 GCS of 15.
Expected Outcome: At the end of 3 days duty, patient will be able to maintain good skin integrity, and good muscle strength.
Nursing Interventions
Rationale
1.Monitored the vital signs, assess braden scale, and GCS of To have a baseline data, identification of nursing intervention, and to
the patient every hour.
2.Assisted patient reposition at least every hour (supine, or

monitor for complications.

Reduces risk of tissue injury. Affected side has poorer circulation and

36

side lying) to shift weight at regular intervals.

3. Assisted patient in active or passive ROM.
4. Provide patient rest periods.
5. Emphasized the importance of passive or active ROM

reduced sensation and is more predisposed to skin breakdown.

Minimize muscle atrophy and promotes circulation.
Reduces fatigue and O2 demand.
To promote wellness.

exercises to the client and family.

6. Stressed the importance of providing restful environment

To facilitate recuperation of the patient. Progressive activity provides

for patient after periods of active or passiveROM exercise.

a controlled demand on the heart, increasing strength and preventing

overexertion.
Evaluation: Goal partially met. At the end of 3 days of duty, the patient is still in bed rest, with GCS 15, left sided body weakness,
BP of 160/60, HR of 97, Braden Scale of 16 and with absence of pressure sores.
References:Valenti, L., Rozinski, M., &Tamblyn, R. (1998). Lippincotts Review Series: Critical Care Nursing. Lippincott Williams
and Wilkins: Philadephia
Doenges, M., Moorehouse, M., &Murr, A. (2008). Nurses Pocket Guide: Diagnoses, Prioritized Interventions, and
Rationales. iGroup Press Co., Ltd.: Thailand
Nurse Theory.(n.d.). Activity intolerance. Retrieved October 4, 2016 from Nurse Theory:
http://www.nursetheory.com/activity-intolerance/
Nurseslabs. (2012, December). NCP CVD impaired physical mobility. Retrieved October 3, 2016, from Nurseslabs:
http://nursinginterventionsrationales.blogspot.com/2013/07/impaired-physical-mobility.html

Risk for impaired skin integrity related to decreased mobility as evidenced by left sided weakness
Cues (Objectives): The patient is on bed rest, with no bathroom privileges, and needs assistance in turning, GCS 14 and Braden
Scale is 16 (Sensory-4, Moisture-3, Activity 1, Mobility 3, and Nutrition-3).
Expected Outcome: After 3 days of duty in the ICU, the patient will be able to maintain tissue integrity as evidence by no skin
breakdown.
Nursing Interventions (OME)

Rationale

37

1. Determine clients risk for skin breakdown using risk

Prior assessment is critical for proper identification of nursing

assessment tool such as Braden Scale.

2. Check patients skin for edema.
3.Inspect the pressure areas of the patients skin, especially

interventions. Immobility is the utmost risk factor in skin breakdown.

Skin stretched tightly over edematous tissue is at great risk for injury.
Establish comparative baseline providing opportunity for timely

bony prominences and dependent areas, for pallor, warmth,

intervention. Health skin differs from person to person, but must have

redness, and breakdown

a good turgor, feel warm and dry to touch, be free of injury, and have

fast capillary refill (<3 seconds).

4. Inspect the quantity of shear and friction on patients skin. Frequent causes of friction compromise the patient rubbing heels or
5. Monitor clients skin care practices, noting type of soap

elbows against bed linen.

Avoid harsh cleansing agents, hot water extreme friction or force or

or other cleansing agents used, temperature of water, and

cleansing too frequently.

frequency of skin cleansing.

6. Turn patient every hour.

To avoid unnecessary pressure on skin, and to promote good

7. Provide bony prominences, heel, or elbow protectors, or

circulation.
Reduces the pressure on tissues, avoiding skin breakdown.

pillows.
8. Maintain linens dry and free of wrinkle, crumbs.
9. Rise lower extremities occasionally.
10. Educate patient and caregiver the reason(s) of pressure

Moisture exacerbates pruritus and augments risk of skin breakdown.

Improves venous return. Decreases edema formation.
Provide knowledge, and to avoid the development of pressure sores.

ulcer development (e.g., pressure on the skin, particularly

bony prominences, incontinence, poor nutrition, shearing or
friction against skin).
Evaluation: Goal met. After 3 days of duty in the ICU, the patient has no presence of bedsore, Braden Scale is still 16, with no
evidence of possible tissue breakdown.
Reference:Valenti, L., Rozinski, M., &Tamblyn, R. (1998). Lippincotts Review Series: Critical Care Nursing. Lippincott Williams
and Wilkins: Philadephia

38

Doenges, M., Moorehouse, M., &Murr, A. (2008). Nurses Pocket Guide: Diagnoses, Prioritized Interventions, and
Rationales. iGroup Press Co., Ltd.: Thailand
Nurseslabs. (2012, December 2016). NCP CVA Unilateral Neglect. Retrieved October 3, 2016, from Nurseslabs:
https://www.scribd.com/doc/117005199/NCP-CVA-Unilateral-Neglect

Deficient self-care (bathing, hygiene, toileting, dressing, grooming, and feeding) related to body weakness, as evidenced by
complete bed rest.
Cues (Objectives): The patient is with left sided weakness, no bathroom privileges, with nasogastric tube on left nostril, and needs
assistance in performing ADL, Braden Scale of 16 with a GCS of 14.
Expected Outcome: After 8 hours of nursing intervention, the patient will be able to achieve and maintain good hygiene as
evidence by satisfying appearance and good grooming.
Nursing Interventions
1. Assessed ability to carry out ADLs on regular basis.

Rationale
Provides data regarding mobility and ability to perform activities

Determine the aspects of self-care that are problematic to

with in limitations without injury.

the patients.
2. Assessed specific cause of each deficit (e.g. weakness).

Different etiologic factors may require more specific interventions to

3. Plan or schedule activities to prevent fatigue during

enable self-care.
Planning conserves energy and minimizes the workload of the heart

bathing.
4. Performed AM care.
5. Provide privacy during bathing, dressing and during

to pump blood.
To provide comfort and enhance well-being.
The need for privacy id fundamental for most patients.

changing of soiled linens as appropriate.

6.Provided oral care with Bactidol (Hexetidine) 15-20 mL

Indicated for general oral hygiene, protects tooth surfaces against

7. Provided adequate rest periods.

formation of decay acids.

To promote comfort relaxation, and to reduce the workload and

39

8. Administered due OTF 100cc q3 hours.

10.Changed soiled diapers, linens, hospital gown. Clean

oxygen consumption, reducing complications.

For fluid replacement and nutrition of the patient.
Cleaning promotes comfort and helps to maintain skin integrity.

buttocks and perineal area with water and pat dry with
tissue.
11. Emphasize the importance of maintaining good hygiene

To prevent the development of infections and bad odors.

to the client and family.

Evaluation: Goal met. At the end of 8 hours of duty, the patient was able to achieve and maintain good hygiene as evidenced by
good grooming and clean appearance.
References:Valenti, L., Rozinski, M., &Tamblyn, R. (1998). Lippincotts Review Series: Critical Care Nursing. Lippincott Williams
and Wilkins: Philadephia
Doenges, M., Moorehouse, M., &Murr, A. (2008). Nurses Pocket Guide: Diagnoses, Prioritized Interventions, and
Rationales. iGroup Press Co., Ltd.: Thailand
Nurseslabs. (2012, December 2016). NCP Self-care deficit. Retrieved from October 3, 2016, from Nurseslabs:
https://www.scribd.com/doc/117005096/NCP-CVA-Self-Care-Deficit

40

Discharge Summary
Nursing Goals
Medication

Orders

Upon Discharge, the Administer

Rationale
prescribed To have a

patient will be able to:

medications at the right time such faster recovery

-Verbalize compliance

as:

to prescribe

medication regimen

Sultamicillin 750g 1tab BID x 3

days until September 15 (8am-

6pm)
Citicoline (Zynapse) 1g/tab OD

AM AC breakfast (7am)
Solifenacin Succinate (Vesicare)
5g 1tab OD AM x 2 days more

Sept 14 (7am)
Atorvastatin (Lipitor) 40mg

1tab OD HS (8pm)
Clopidogrel (Platexan) 75g 1tab

OD PC lunch (1pm)
Losartan + Amlodipine 50/5mg

1tab OD AM (8am)
NAC (Exflem) 600mg/5ml
water ODHS x 3 days then pm

for cough September 15 (8pm)

Pregabalin (Funxion) 50mg

cap/1 cap OD HS (8pm)

Piracetam (Nurocer) 1.2g/tab

OD PC Lunch (1pm)
KCL tab (K Lyte) 600mg/tab
BID x 4 doses until sept 14

(8am-6pm)
Glimiperide (Norizec) 2mg/tab
OD AC before Breakfast, hold
for RBS<100 (7am)

of the patient

41

Exercise tongue 10 times every

morning. Exercise the extremities
Exercise

Verbalize

by bending or rotating slowly.

To improve

understanding on the Light Activities.

motor function

importance of tongue

& maintain

exercise

muscle tone.

&

light

activities.

Referred to physical therapist for

physical therapy.

Therapy

Patient will be able to

To decrease

restore

viscosity of

muscle

strength

&

have

adequate

motor

body

&

secretions on

functional activities.

the airways
Encourage

patient

to

perform and lungs

appropriate hygiene (e.g. bathing,

Hygiene

Verbalize

grooming, & oral hygiene).

To achieve &

understanding on the

maintain good

importance

of

hygiene to

maintaining

good

prevent

hygiene.

development
of infections
and avoid foul
Follow up check-up on Room 306 odors.
Medical Plaza, September 13,

OPD

Identify

further 2016 (call for appointment), Dr. To have

unusualities and have Reynaldo A. Wong.

check-up

updates on

whenever Follow-up with Dr.Geroches for patient care

there is recurrence of Uro problems.

and to check if

the symptoms of CVD

there are

42

Low Salt Diet; Low Fat Diet

Diet

progress

Report significance of

To have good

balanced nutrition and

nutrition and

healthy

optimal body

body

condition

-----------------------------------------

Spiritual

conditioning
To have Gods

State the importance

guidance and it

of

will help him

healthy spiritual

life by worshipping

to be healed

God

faster

and

everyday

praying

43

CHAPTER IV
GENERAL EVALUATION OF THE STUDY
This chapter comprises the implication of the study (Nursing Practice, Nursing
Education, Nursing Service, and Nursing Researcher), the personal reaction of the group, and the
bibliography.
A. Implication of the Study
We the researchers would like to recommend the following to:
Nursing Practice
To the nursing practice, the researchers would like to recommend for the continuity of
education to its practitioners in concepts and skills required for practice, focusing especially on
the population, PHN practice, advocacy for more public health resources, and collaboration with
academic partners for education and research.
Nursing Education
To the nursing education, the researchers would like to recommend the need for highlyeducated nurses. The ways in which nurses were educated during the 20 th century are no longer
adequate for dealing with the realities of health care in the 21 st century. As patient needs and care
environments have become more complex, nurses need to attain requisite competencies to
deliver high-quality care. These competencies include leadership, health policy, system
improvement, research and evidence-based practice, and teamwork and collaboration, as well as
competency in specific content areas such as community and public health and geriatrics.

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Nursing Service
To the nursing service, the researchers would like to recommend an assurance to a
sufficient continuing supply of new applicants, nurse educators and national nursing
organizations should adopt recruitment strategies that attract not only recent high school
graduates but also nontraditional prospective students, such as those seeking late entry into a
profession or seeking to change careers, and minorities. Closer collaboration between nurse
educators and nurses who provide patient services is essential to give students an appropriate
balance of academic and clinical practice perspectives and skills during their educational
preparation.
Nursing Researchers
To the nursing researchers, the researchers would like to encourage future nursing
researchers to take interest in cases like this, to develop a more quality type of care for such
patients based on the appropriate knowledge gained through research. Also to delve a little
deeper on the case in order to make appropriate care needed for the patients and be able to share
gained knowledge and insights to co-researchers as well regarding the case being studied to help
expand the knowledge of others in order to achieve a more quality kind of care.
B. Personal Reaction
We are indeed fortunate that we were able to care for a client with Cerebrovascular Disease.
Although it is one of the most common diseases, it has been a great opportunity that we were
able to gain experience, study and dig a little deeper about the background and the formulation of
care essential for the client with the said disease. Before, we had a little understanding about

45

Cerebrovascular Disease and because of this study, we gained better and clearer discernment
how the disease progressed.
This study also adds our perception in the importance of each prescribed medications and
special consideration that is given for clients with Cerebrovascular Disease. Throughout this
study, we were able to develope our personal skills and the formulation of our discharge
summary to our chosen patient.
For the purpose of this study, we hope that it will also guide and expand the horizon of the
reader in their breakthrough of their clients care.

46

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