I.

Introduction
A stroke is a cerebrovascular accident, or what is now being termed as Brain attack is a sudden loss of brain function resulting from disruption of blood supply to a part of the brain resulting from pathologic blood vessels. It denotes an abnormality of the brain. Stroke can be classified into Ischemic and Hemorrhagic strokes. Ischemic stroke can be divided into thrombotic and embolic stroke. Thrombotic stroke results from the narrowing or occlusion of blood vessels from a blood clot originating from the other parts of the body most commonly from the heart. In the Philippines, it is the most common with 70% of cases. In addition, Bader and Littlejohns (2004) stated that hemorrhagic stroke accounts for 15% to 20% of cerebrovascular disorder and it was further classified into intracerebral hemorrhage and subarachnoid hemorrhage. Hemorrhagic strokes are caused by bleeding into the brain tissue, the ventricles or the subarachnoid space. Primary intracerebral hemorrhage from a spontaneous rupture of a small vessels accounts for approximately 80% of hemorrhagic strokes and is caused chiefly by uncontrolled hypertension, atherosclerosis and cerebral amyloud angiopathy. Secondary intracerebral hemorrhage is associated with arteriovenous malformation (AVMs) intracranial aneurysm, intracranial neoplasms or certain medications. In addition, Smeltzer, et. Al (2008) enumerated that advanced age, gender, and race are well known nonmodifiable risk factors for stroke. Modifiable risk factors for hemorrhagic stroke include hypertension, hyperlipidemia, obesity, smoking and diabetes. According to Smeltzer and Bare, (2004) hemorrhagic stroke can present with a wide variety of neurologic deficits, similar to a patient with ischemic stroke. The conscious patient mostly common reports a severe headache, vomiting, an early sudden change in level of consciousness, there may be visual disturbances (visual loss, diplopia, ptosis), motor deficits (hemiparesis, hemiplegia, ataxia, dysarthria, dysphagia) sensory deficits (paresthesia), verbal deficits (expressive aphasia, receptive aphasia, global aphasia), cognitive deficits and emotional deficits. To assess the client with hemorrhagic stroke, some diagnostic exams were needed to perform. Any patient with suspected stroke should undergo CT scan to determine the type of stroke and the size and location of hematoma. Lumbar puncture is performed if there is no evidenced of increased ICP, the CT scan results are negative and subarachnoid hemorrhage must be confirmed. Moreover, Mayer, Brun, Begtrup, et. Al (2005) cited the goals of medical treatment for hemorrhagic stroke are to allow the brain to recover from the initial attack (bleeding), to prevent or minimize the risk for rebleeding, and to prevent or treat complications. Management is primarily supportive and consists of bed rest with sedation to prevent agitation and stress. Analgesics (codeine, acetaminophen) may be prescribed for head and neck pain. In addition, treatment of intracerebral hemorrhage differs from that of an ischemic stroke. Anticoagulants (such as heparin and warfarin). Thrombolytic drugs and antiplatelet drugs (such as aspirin) are

not given because they make bleeding worse. If people who are taking an anticoagulant have a hemorrhagic stroke, they may need a treatment that helps blood clot such as; Vitamin K, usually given intravenously, Transfusions of platelets, Transfusions of blood that has had blood cells and platelets removed (fresh frozen plasma), Intravenous administration of a synthetic product similar to the proteins in blood that help blood to clot (clotting factors). According to Hickey (2003), surgical evacuation is most frequently accomplished via craniotomy. Morbidity and mortality from surgery are high if the patient is sturporous or comatose. Surgical treatment of the patient with an unruptured aneurysm is an option. The goal o surgery is to prevent bleeding in an unruptured aneurysm. Moreover, Black and Hawkes (2008) cited that client education is aimed at stroke prevention. Primary prevention of stroke includes the following: maintaining safe cholesterol levels, smoking cessation; using low dose estrogen contraceptives only in the absence of other risk factors, reducing alcohol consumption, and eliminating illicit drug use. Secondary prevention includes the following: adequate blood pressure control; care of diabetes mellitus, and treatment of cardiovascular disease, TIA, and atrial fibrillation. Prognosis depends on the neurologic condition of the patient, the patients age, associated disease, and the extent and location of the hemorrhage or intracranial aneurysm. Subarachnoid hemorrhage is a catastrophic event with significant morbidity and mortality. The primary concern of this study is to further enhance the understanding of CVA accident in congruence with the learned concepts of the nursing students. This case study emphasizes detailed assessment of the subject as a whole. It determines the past history, present history of illness, social history and family history as these may affect overall health. Furthermore, this study examines the self care practices that the patient observed in maintenance of this health. Likewise, it reviews the ways in which the patient addresses/satisfies her physiologic needs as nutrition, activity, sleep, fecal and urinary elimination, and hygiene.

II.PATIENT PROFILE/PERSONAL DATA

Name: Age: Address: Birth date: Place of Birth: Sex: Civil Status: Nationality: Religion: Chief Complaint: Date of admission: Time of Admission: Admitting Physician: Clinical Impression: Mrs. R.I.E. 81 years old Poblacion, Morong, Bataan June 18, 1949 Bicol Female Married Filipino Roman Catholic Right Sided body weakness 1 day prior to admission August 18, 2011 1:50 p.m Dra.Guttierez Stroke secondary to HPN.

III.PERSONAL-SOCIAL HISTORY
The client always wants to eats salty foods like snacks, noodles, fatty foods like chicharon baboy and also she wants to eat meat foods and fish. She is also a smoker and she started to smoke at the age of 25, and she spends 3 stick of cigarettes per day, but she stopped smoke at the age of 65.She usually sleep on time and she sleep for about 6-8 hours. She has 8 siblings, 5 males and 3 females and the 2 females works as a helper in some of their relatives to support their family. According to her daughter, they have a good family relationship. She did not enter high school and college and she only enter grade 1 and she need to stop because of financial problem. She works as a helper in their relatives and she usually walks going to her work but at the age of 60 she stopped working because of her condition. As stated by her daughter, their life is quiet hard, because the money that they earn is not sufficient for their everyday lives. According to her daughter their residence is compound-like and near from the beach, some of their neighbor is their relatives and some are friends. They dont have any problems in their neighbors in terms of relationship.

IV. Past Medical History

Her sixth daughter, Mrs. C.E states that her mother who is Mrs. R.E (the patient) had suffered from radiating pelvic pain since the end of year 2004. Due to the recurrent pain felt in the pelic area and during urination, Mrs. R.E had her medical check ups to Dr. Bustamante and it results to UTI. The first check-up was done on March 16,2005 followed by her second checkup on April 16, 2004 still due to UTI. She was been instructed to take Ciprofloxacin 500mg tab B.I.D for her UTIandNicardipine capsule T.I.D after finding out of elevated BP. These medications were discontinued immediately due to their financial crisis. Also, her daughter claimed that Mrs. R.E doesnt have any vitamins maintainance and had never gone confinement due to hypertension.

V. Present Medical History

Admitted at Bataan Provincial Hospital last August 18, 2011 at 1:50 pm with a chief complaint of Right body weakness. Few hours PTA, according to her daughter, Mrs. R.E suffered from severe headache and dizziness and she fall upon standing due to the complain of blurring of vision. Mrs. R.Es daughter rushed her to hospital (BPH) and she was been confined with a admitting diagnosis of CVA broad vs. infection with a initial vital signs of: BP:200/100, Temp:35.4 , PR:52, RR:38 . She was requested for CBC, Na, K, BUN, Creatinine, ABG, Lipid profile, U/A and CXR. The results on her creatinine and BUN shows in increase level. For CXR, it shows cardiomegaly with mild pulmonary congestion. On her CBC results, the hematocrit and hemoglobin count also decreases while the WBC increases. During her hospitalization, medications have been administered as follows: Mannitol, citicholine, Ciprofloxacin, Paracetamol, Diazepam and combivent nebulizer.

VI. FAMILY HISTORY (GENOGRAM)

75 HTN

60 HTN

81 CVA

65 CVA

53 CVA

76

71 CVA

73 CVA

71

68

57

56

55

53

49

47

44

29 Hepa B

41

40

LEGENDS:

=Alive Female

=Alive Male

=Deceased Male

=Deceased Female

VIII. PATTERNS OF DAILY LIVING

Activity Nutrition

Before hospitalization She usually eats salty foods such as canned goods and noodles, meat such as pork, fatty foods such as chicharon baboy, and liempo. She also fonds of eating sweets such as candies and chocolates.

During hospitalization In her confinement, due to paralysis of the right side of the body, difficulty of breathing and severe body malaise, she is not able to eat anything. When her daughter tends to feed her, she usually vomits.

Exercise

She is not active in any form of She is not engage in any exercise. She had a sedentary exercise due to paralysis lifestyle. and unable to ambulate. She has a regular pattern of sleeping. She sleeps at night at 9 o'clock then woke up in the morning at 5 o'clock. She also takes a nap for 2-3 hours. When she was confined, she is frequently sleeping. Within the day she is sleeping for about 15 hours.

Sleep and rest

Elimination

STOOL: PTA he usually STOOL: she did not defecates once a day. He is not eliminate for his whole also constipated. confinement.

URINE: she frequently urinates 10 times a day, her urine is URINE: she has a foley hazy. catheter connected to a urine bag. Within an hour her urine is 30ml. Activities She had been a smoker since She cannot perform any 25 years old, 3 sticks a day then extra activities now due to stopped at the age of 65 years paralysis old

IX. PHYSICAL ASSESSMENT

Vital signs BP Temp PR RR August 23, 2011 200/100mmHg 35.4C 52bpm 38cpm

Body parts Skin

Technique Inspection

Findings Brown shade black Dry, flaky to

Interpretation Normal Sebaceous and sweat glands are less active; normal with aging Due to decrease oxygen supply in the body. Loss of dermis and subcutaneous fats; normal with aging. Decrease elasticity of the skin due to aging. Due to aging Normal

Pale noted Appears thin and translucent When pinched, skin springs back slowly to previous state Mixture of black and white in color hair Free from infestation and alopecia Lighter in color than the complexion Moist No scars No lesions Free from lice and dandruff No tenderness and masses

Palpation Hair Inspection Palpation

Palpation Scalp Inspection

Normal Normal Normal Normal Normal Normal

Skull

Inspection Palpation

Normocephalic No tenderness upon palpation Shape: oval Positive peripheral facial drooping Paralysis of the right side of the face. Evenly placed and symmetrical with each other Usually shut

Normal Normal Normal Due to paralysis Due to a lesion in the opposite cerebral hemisphere. Normal Due to paralysis and generalized body weakness. Normal Normal Normal Normal Normal Normal Normal Due to paralysis of the right side of the body. Normal

Face

Inspection

Eyes

Inspection

Eyebrows

Inspection

Symmetrical and in line with others Black in color Evenly distributed Black in color Evenly distributed Turned outward Symmetrical PTOSIS note Meets completely when the eyes are closed Non palpable No tenderness Pale in color Moist No ulcers No foreign objects With presence of capillaries Anicteric Some capillaries are visible

Eyelashes

Inspection

Eyelids

Inspection

Lacrimal apparatus Conjunctiva

Palpation

Normal Normal Abnormal due to decreased oxygen perfusion Normal Normal Normal Normal Normal Normal

Inspection

Sclera

Inspection

Cornea Pupils

Inspection Inspection

Looks smooth Clear Sluggish Non reactive to light and accomodation Black in color E ar lobes are bean shaped Parallel with each other Symmetrical Skin is the same in color in the complexion No lesions noted on inspection Auricles has a firm cartilage The pinna recoils when folded No pain and tenderness In the midline No discharges Both nares are patent with flaring of nostrils no tenderness pale in color no tenderness drooping pale in color noted dry no edema

Normal Normal Abnormal, due to decreased oxygen perfusion. Due to damage on cranial nerve:optic Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Due to difficulty of breathing normal Due to decrease blood perfusion Normal Due to paralysis of the right side of the body Due to decrease oxygen supply Decreased salivary gland activity; normal with aging Normal

Ears

Inspection

Palpation

Nose

Inspection

Palpation Nasal mucosa Inspection Palpation Mouth (lips) Inspection

Palpation

Gums

Inspection

no pain/ tenderness on palpation and during jaw movement pale noted no bleeding noted all teeth are loss no halitosis Pale keep moist saliva by

Normal

Teeth Buccal mucosa

Inspection Inspection

Due to decrease oxygen supply normal Due to aging Normal Due to decrease oxygen supply Normal

Tongue

Inspection

pale with white taste buds no lesions noted no varicosities on ventral surface gag reflex absent

Due to decrease oxygen supply Normal Normal Due to motor and sensory dysfunction Compression of cranial nerves and brain tissue Due to decrease production of saliva. Normal Due to decrease oxygen supply normal

Neck Inspection Trachea Palpation

Palpation Uvula Inspection

Tongue is retracted with thick mucus. Unable to move. surface of tongue is rough positioning in the midline pale no swelling lesion noted or

neck is straight no visible mass or lumps symmetrical veins are not distended Trachea is palpable Positioned in the midline and

normal normal normal normal Normal Normal

Lymph nodes Thyroid Chest

Palpation Palpation Inspection

straight Non tender Slightly movable Non palpable Symmetrical Use of accessory muscle With crackle breath sounds on both lungs

Normal Normal Normal Normal Abnormal, due to increased oxygen demand Abnormal, due to fluid accumulation in the lungs, pulmonary congestion. Due to difficulty of breathing Normal Normal Due to decrease cardiac tissue perfusion and cardiomegaly Normal Abnormal, due to constipation Normal Abnormal, due to decreased oxygen perfusion Abnormal due to altered circulation Abnormal due to reduced peripheral circulation Due to paralyzed muscles which result in decreased active muscle pump for removing excess fluid

Lungs

Auscultation

Heart Inspection

RR: 38cpm Apical pulse is not visible No heaves and thrills PR: 52bpm

Abdomen

Inspection Auscultation Palpation

No lesions/ scars noted Decrease bowel sounds No tenderness Pale Cold to touch Capillary refill > 3 seconds With pitting edema

Upper extremities

Inspection

Palpation

Lower extremities

Inspection

Pale Cold to touch Capillary refill > 3 seconds With pitting edema

Palpation

Positive sign

homan's

Abnormal, due to decreased oxygen perfusion Abnormal due to altered circulation Abnormal due to reduced peripheral circulation Due to paralyzed muscles which result in decreased active muscle pump for removing excess fluid Due to clotting of blood in the valves of deep calf veins; sign of thrombophlebitis Due to immobility

Genital

Inspection

With IFC

Glascgow Coma Scale

4 3 2 1

6 5 4 3 2 1

5 4 3 2 1

08-23-11 Best eye opening Spontaneous To speech To pain None Best motor response Obeys command Localizes pain Withdraw Decorticate Decerebrate None Best verbal response Oriented Confuse speech Inappropriate Incomprehen sible None Total Sensorium Awake Drowsy Stuporous Comatose Vegetative

10

11

12

PHYSICAL ASSESSMENT Vital signs BP Temp PR RR August 24, 2011 180/110mmHg 37.4C 60bpm 35cpm

Body parts Skin

Technique Inspection

Findings Brown shade black Dry, flaky to

Interpretation Normal Sebaceous and sweat glands are less active; normal with aging Due to decrease oxygen supply in the body. Loss of dermis and subcutaneous fats; normal with aging. Decrease elasticity of the skin due to aging. Due to aging Normal

Pale noted Appears thin and translucent When pinched, skin springs back slowly to previous state Mixture of black and white in color hair Free from infestation and alopecia Lighter in color than the complexion Moist No scars No lesions Free from lice and dandruff No tenderness and masses

Palpation Hair Inspection Palpation

Palpation Scalp Inspection

Normal Normal Normal Normal Normal Normal

Skull

Inspection Palpation

Normocephalic No tenderness upon palpation Shape: oval Positive peripheral facial drooping Paralysis of the right side of the face. Evenly placed and symmetrical with each other Usually shut

Normal Normal Normal Due to paralysis Due to a lesion in the opposite cerebral hemisphere. Normal Due to paralysis and generalized body weakness. Normal Normal Normal Normal Normal Normal Normal Due to paralysis of the right side of the body. Normal

Face

Inspection

Eyes

Inspection

Eyebrows

Inspection

Symmetrical and in line with others Black in color Evenly distributed Black in color Evenly distributed Turned outward Symmetrical PTOSIS note Meets completely when the eyes are closed Non palpable No tenderness Pale in color Moist No ulcers No foreign objects With presence of capillaries Anicteric Some capillaries are visible

Eyelashes

Inspection

Eyelids

Inspection

Lacrimal apparatus Conjunctiva

Palpation

Normal Normal Abnormal due to decreased oxygen perfusion Normal Normal Normal Normal Normal Normal

Inspection

Sclera

Inspection

Cornea Pupils

Inspection Inspection

Looks smooth Clear Sluggish Non reactive to light and accomodation Black in color E ar lobes are bean shaped Parallel with each other Symmetrical Skin is the same in color in the complexion No lesions noted on inspection Auricles has a firm cartilage The pinna recoils when folded No pain and tenderness In the midline No discharges Both nares are patent with flaring of nostrils no tenderness pale in color no tenderness drooping pale in color noted dry no edema

Normal Normal Abnormal, due to decreased oxygen perfusion. Due to damage on cranial nerve:optic Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Due to difficulty of breathing normal Due to decrease blood perfusion Normal Due to paralysis of the right side of the body Due to decrease oxygen supply Decreased salivary gland activity; normal with aging Normal

Ears

Inspection

Palpation

Nose

Inspection

Palpation Nasal mucosa Inspection Palpation Mouth (lips) Inspection

Palpation

Gums

Inspection

no pain/ tenderness on palpation and during jaw movement pale noted no bleeding noted all teeth are loss no halitosis Pale keep moist saliva by

Normal

Teeth Buccal mucosa

Inspection Inspection

Due to decrease oxygen supply normal Due to aging Normal Due to decrease oxygen supply Normal

Tongue

Inspection

pale with white taste buds no lesions noted no varicosities on ventral surface gag reflex absent

Due to decrease oxygen supply Normal Normal Due to motor and sensory dysfunction Compression of cranial nerves and brain tissue Due to decrease production of saliva. Normal Due to decrease oxygen supply normal

Neck Inspection Trachea Palpation

Palpation Uvula Inspection

Tongue is retracted with thick mucus. Unable to move. surface of tongue is rough positioning in the midline pale no swelling lesion noted or

neck is straight no visible mass or lumps symmetrical veins are not distended Trachea is palpable Positioned in the midline and

normal normal normal normal Normal Normal

Lymph nodes Thyroid Chest

Palpation Palpation Inspection

straight Non tender Slightly movable Non palpable Symmetrical Use of accessory muscle With crackle breath sounds on both lungs

Normal Normal Normal Normal Abnormal, due to increased oxygen demand Abnormal, due to fluid accumulation in the lungs, pulmonary congestion. Due to difficulty of breathing Normal Normal Due to decrease cardiac tissue perfusion and cardiomegaly Normal Abnormal, due to constipation Normal Abnormal, due to decreased oxygen perfusion Abnormal due to altered circulation Abnormal due to reduced peripheral circulation Due to paralyzed muscles which result in decreased active muscle pump for removing excess fluid

Lungs

Auscultation

Heart Inspection

RR: 38cpm Apical pulse is not visible No heaves and thrills PR: 52bpm

Abdomen

Inspection Auscultation Palpation

No lesions/ scars noted Decrease bowel sounds No tenderness Pale Cold to touch Capillary refill > 3 seconds With pitting edema

Upper extremities

Inspection

Palpation

Lower extremities

Inspection

Pale Cold to touch Capillary refill > 3 seconds With pitting edema

Palpation

Positive sign

homan's

Abnormal, due to decreased oxygen perfusion Abnormal due to altered circulation Abnormal due to reduced peripheral circulation Due to paralyzed muscles which result in decreased active muscle pump for removing excess fluid Due to clotting of blood in the valves of deep calf veins; sign of thrombophlebitis Due to immobility

Genital Body parts Skin

Inspection Technique Inspection

With IFC

Findings Brown shade black Dry, flaky to

Interpretation Normal Sebaceous and sweat glands are less active; normal with aging Due to decrease oxygen supply in the body. Loss of dermis and subcutaneous fats; normal with aging. Decrease elasticity of the skin due to aging.

Pale noted

Appears thin and translucent

When

pinched,

skin springs back slowly to previous state

Palpation

Hair

Inspection

Palpation Scalp Inspection

Mixture of black and white in color hair Free from infestation and alopecia Lighter in color than the complexion Moist No scars No lesions Free from lice and dandruff No tenderness and masses

Due to aging

Normal Normal

Normal Normal Normal Normal Normal

Palpation Skull Inspection Palpation Face Inspection Normocephalic No tenderness upon palpation Shape: oval Positive peripheral facial drooping Paralysis of the right side of the face. Normal Normal Normal Due to paralysis Due to a lesion in the opposite cerebral hemisphere. Normal

Eyes

Inspection

Evenly placed and symmetrical with

each other Usually shut Due to paralysis and generalized body weakness.

Eyebrows

Inspection

Symmetrical and in line with others Black in color Evenly distributed

Normal Normal Normal Normal Normal Normal Normal Due to paralysis of the right side of the body. Normal

Eyelashes

Inspection

Eyelids

Inspection

Black in color Evenly distributed Turned outward Symmetrical PTOSIS noted

Lacrimal apparatus Conjunctiva

Palpation

Meets completely when the eyes are closed Non palpable No tenderness Pale in color

Normal Normal Abnormal due to decreased oxygen perfusion Normal Normal Normal Normal Normal Normal

Inspection

Sclera Inspection Moist No ulcers No foreign objects With presence of capillaries Anicteric Some capillaries are visible

Cornea Pupils

Inspection Inspection

Looks smooth Clear Sluggish

Normal Normal Abnormal, due to decreased oxygen perfusion. Due to damage on cranial nerve:optic

Ears

Inspection

Non reactive to light and accomodation Black in color E ar lobes are bean shaped Parallel with each other Symmetrical Skin is the same in color in the complexion No lesions noted on inspection Auricles has a firm cartilage The pinna recoils when folded No pain and tenderness

Normal Normal Normal

Normal Normal

Normal Normal

Palpation

Normal

Nose

Inspection

In the midline No discharges Both nares are patent with flaring of

Normal Normal Normal Normal

nostrils no tenderness

Due to difficulty of breathing normal

Palpation Nasal mucosa Inspection pale in color no tenderness drooping Palpation pale in color noted dry Due to paralysis of the right side of the body Due to decrease oxygen supply Decreased salivary gland activity; normal with aging Normal Normal Due to decrease blood perfusion Normal

Palpation Mouth (lips) Inspection

Gums

Inspection

no edema no pain/ tenderness on palpation and during jaw movement pale noted no bleeding noted all teeth are loss no halitosis pale

Due to decrease oxygen supply normal

Teeth Buccal mucosa

Inspection Inspection

Due to aging Normal Due to decrease oxygen supply Normal

 Tongue Inspection

keep moist by saliva pale with white taste buds no lesions noted no varicosities on ventral surface gag reflex absent

Due to decrease oxygen supply Normal Normal Due to motor and sensory dysfunction Compression of cranial nerves and brain tissue Due to decrease production of saliva. Normal Due to decrease oxygen supply normal

Tongue is retracted with thick mucus. Unable to move. surface of tongue is rough

Palpation Uvula Inspection positioning in the midline pale no swelling lesion noted or

Neck

Inspection

neck is straight no visible mass or lumps symmetrical veins are not distended Trachea is palpable Positioned in the midline and straight

normal normal normal normal Normal Normal

Trachea

Palpation

Lymph nodes Thyroid Chest

Palpation Palpation Inspection

Non tender Slightly movable Non palpable Symmetrical Use of accessory muscle With crackle breath sounds on both lungs

Normal Normal Normal Normal Abnormal, due to increased oxygen demand Abnormal, due to fluid accumulation in the lungs, pulmonary congestion. Due to difficulty of breathing Normal Normal

Lungs

Auscultation

RR: 38cpm Apical pulse is not visible No heaves and thrills PR: 52bpm

Heart

Inspection

Abdomen

Inspection

Auscultation

No lesions/ scars noted Decrease bowel sounds No tenderness

Due to decrease cardiac tissue perfusion and cardiomegaly Normal Abnormal, due to constipation Normal

Palpation Upper extremities Inspection Pale Palpation Cold to touch Capillary refill > 3 Abnormal, due to decreased oxygen perfusion Abnormal due to altered circulation Abnormal due to reduced peripheral circulation

seconds

With pitting edema

Due to paralyzed muscles which result in decreased active muscle pump for removing excess fluid

Lower extremities

Inspection

Pale

Cold to touch Capillary refill > 3 seconds

With pitting edema

Abnormal, due to decreased oxygen perfusion Abnormal due to altered circulation Abnormal due to reduced peripheral circulation Due to paralyzed muscles which result in decreased active muscle pump for removing excess fluid Due to clotting of blood in the valves of deep calf veins; sign of thrombophlebitis

Genital Inspection

Positive homan's sign With IFC

Due to immobility

Glascgow Coma Scale

4 3 2 1

6 5 4 3 2 1

5 4 3 2 1

08-24-11 Best eye opening Spontaneous To speech To pain None Best motor response Obeys command Localizes pain Withdraw Decorticate Decerebrate None Best verbal response Oriented Confuse speech Inappropriate Incomprehen sible None Total Sensorium Awake Drowsy Stuporous Comatose Vegetative

10

11

12

X. LABORATORIES/DIAGNOSTIC PROCEDURES Blood chemistry Date: 8-19-11

Component
BUN

Normal value Result

62-120mmol/L 2.5-7.5mmol/L

Interpretation
Indicates normal kidney excretion. Indicates decreased kidney function. Indicates risk for heart attack and stroke. Has normal level of triglycerides to be used as energy of the body.

CREATININE

0.8-1.2mmol/L

149.7mmol/L

CHOLESTEROL

<6.5

4.7mmol/L

TRIGLYCERIDES

0.46-1.9

1.0mmolL

Hematologic report

Date: 8-19-11

Components
CBC HEMOGLOBIN

Normal value
120-150g/l

Results
102g/l

Interpretation
The normal oxygen carrying capacity of the blood. Has normal pack of RBC/blood viscosity. Indicates capacity. Due to UTI increase WBC

HEMATOCRIT

0.37-0.47

0.31

LYMPHOCYTES

0.40

0.25-0.35

WBC

5.0 x 10 g/L

6.1 x 10 g/L

X-ray
X-ray/utz no: 180638 Name of pt: E.R Date: Aug 15, 2011 Age: 81 Sex: F Type of examination: x-ray Part examined: chest PA Interpretation: cardiomegaly with pulmonary congestion. Aorta is sclerotic degenerative changes of the thoracic spine, diaphragm & sinuses are negative

XI. THEORETICAL FRAMEWORK

APPLICATION OF THE THEORY FOR MRS. R.E SELF CARE this are the activities of daily living which Mrs. R.E perform self care. SELF CARE REQUISITES these are the need of Mrs. R.E that need assisitance, air, water, food , elimination, activity/rest, prevention of hazards, maintain a developmental environment, maintenance of health status, adjust lifestyle to accomodate the health status changes and medical regimen. UNIVERSAL SELF CARE REQUISITES for drainage. Also Mrs. R.E has an IFC connected to urine bag

HEALTH DEVIATION SELF CARE ACTIVITIES these includes the needs of Mrs. R.E ant the measures carried out by the nurtse to meet self care requisites. For her urionation he has an IFC to aid in her urination. THERAPEUTIC SELF CARE DEMAND these are the deficient areas of Mrs. R.E nutrition, fecal and urinary elimination, activity, rest and hygiene. SELF CARE AGENCY. Mrs. R.E ability to perform self care describe her self care agency AGENT. Mrs R.E is the agent DEPENDENT CARE AGENT . Mrs R.E dependent care agent during hospitalization was the nurse and his rlatives. SELF CARE DEFICIT. In Mrs R.E patterns of daily living, she is independent in performing activities such as , bathing , dressing , grooming and oral hygiene. NURSING AGENCY nurses who workede for Mrs. R.E composed the nursing agency. NURSING SYSTEMS. Nursing systems are those actions listed nursing care plan. These listed the independent actions of the nurse and how the client can cooperate to meet his self care therapeutic demand.

XII. ANATOMY AND PHYSIOLOGY

NERVOUS SYSTEM The nervous system is the master controlling and communicating system of the body. Every thought, action and emotion reflects its activity. Its signaling device, or means of communicating with body cells, is electrical impulses which are rapid and specific and cause almost immediate responses. To carry out its normal role the nervous system has three overlapping functions: 1. Much like a sensory, it uses its millions of sensory receptors to monitor changes occurring both inside and outside the body. These changes are called stimuli and gathered information is called sensory input. 2. It processes and interprets the sensory inputs and makes decisions what should be done at each moment a process called integration. 3. It then affects a responds by activating muscles or glands via motor output. The nervous system does not work alone to regulate and maintain body homeostasis; the endocrine system is the second important regulating system. While the nervous system controls with rapid electrical nerve impulses, the endocrine system organs produce hormones that are release into the blood. Thus the endocrine system typically brings about its effect in a more leisurely way. STRUCTURAL CLASSIFICATION The structural classification which includes all nervous system organs has two subdivisions, the Central Nervous Systemand the Peripheral Nervous System. The CNSconsists of the brain and spinal cord, which occupy the dorsal body cavity and acts as the integrating and command centers of the nervous system. The interpret incoming sensory information and issue instructions based on past experiences and current conditions. The PNS the part of the nervous system outside the CNS consist mainly of the nerves that extend from the brain and the spinal cord. Spinal nerves carry Impulses to and from spinal cord. Cranial nerves carry impulses to and from the brain. These nerves serve as communication lines. They link all parts of the body by carrying impulses from the sensory receptors to the CNS and from the PNS to the appropriate glands or muscles. FUNCTIONAL CLASSIFICATION The functional classification scheme is concerned only with PNS structures. It divides into two principle subdivisions.

The sensory or afferent divisions, consists of nerve fibers that convey impulses to the CNS from sensory receptors located in various parts of the body. Sensory fibers delivering impulses from the skin, skeletal muscles and joint calledsomatic sensoryfibers or visceral afferents. The sensory division keeps the CNS constantly informed of events going on both inside and outside of the body. The motor or efferent division carries impulses from CNS to effector organs, the muscles and glands. This impulses activate muscles and glands; that is, they effect (bring about) a motor response. The motor division in turns has two subdivisions: 1. The somatic nervous system allows us to consciously, or voluntarily, controls our skeletal muscles. Hence, this subdivision is often referred to us the voluntary nervous system. However, not all skeletal muscles activity controlled by this motor division is voluntary. Skeletal muscle reflexes like the stretch reflex for example, are initiated in voluntarily by these same fibers. 2. The autonomic nervous system regulates events that are autonomic, or involuntary, such as the activity of smooth and cardiac muscles and glands. This subdivisions commonly called the Involuntary Nervous System, itself has two parts, the sympathetic and parasympathetic, which typically brings about opposite effects.

SUPPORTING CELLS Supporting cells in the CNS are lump together as neuroglia, literally, nerve glue.Neuroglia includes many types of cells that generally supports, insulate and delicate neurons. In additions, each of the different types of neuroglia also simply called glia or glial cells, has special functions. The CNS glia includes: Astrocytes: abundant star-shaped cells that account for nearly half of the neural tissues. Their numerous projections have swollen ends that cling to neurons, bracing them and anchoring them to their nutrient supply lines, the blood capillaries. Astrocytes from a living barrier between capillaries and neurons and play a role in making exchanges between the two. In this way, they helpprotects the neurons from harmful substances that might be in the blood. Astrocytes also help control the chemical environments in the brain by picking up excess ions and recapturing released neurotransmitter. Microglia: spiderlike phagocytes that dispose of debris, including dead brain cells and bacteria. Ependymal cells: these glial cells line the cavities of the brain and the spinal cord. The beating of their cilia helps to circulate the cerebrospinal fluid that fills those cavities and forms a protective cushion around that CNS.

Oligodendrocytes: glia that wraps their flat extensions tightly around the nerve fibers, producing fatty insulating coverings called myelin sheaths.

Although they somewhat resemble neurons structurally, glia are not able to transmit nerve impulses, a function that is highly developed in neurons. Another important difference is that glia nerve loses their ability to divide, whereas most neurons do. Consequently, most brain tumors are gliomas or tumors formed by glial cells (neuroglia). Supporting cells in PNS come in two major varieties Schwann cells and satellite cells. Schwann cells form the myelin sheaths around nerve fibers that are found in the PNS. Satellitecells acts as protective, cushioning cells.

NEURONS Neurons, also called nerve cells, are highly specialized to transmit messages (nerve impulses) from one part of the body to another. Although neurons differ structurally, they have many common features. All have a cell body, which contain the nucleus and is the metabolic center of the cell, and one or more slender processes extending from the cell body.

THE CENTRAL NERVOUS SYSTEM Spinal cord

The spinal cord runs from the base of the skull all the way down in the spine to the tail bone. The neurons are found in an H-shaped space within the spinal vertebrae. There are motor pathways going up to the brain

Brain

The brain is traditionally divided into three parts, the hindbrain the midbrain, and the forebrain. This drawing is roughly what it would look like if you sliced your brain straight down the middle, like a part in your hair. The front of the brain is on the left, the back on the right.

The hindbrain is brain stem consists of three parts. The first is the medulla, which is actually an extension of the spinal cord into the skull. Besides, containing tracts up and down to and from the higher portions of the brain, the medulla also contains some of the essential nuclei that govern respiration and heart rate. The upper part of the medulla contains a pinky-sized complex of nuclei called reticular formation. It is the regulatory system for sleep, walking and alertness. The second part is the pons, which means bridge in Latin, the pons sits in front of the medulla, and wraps around it to back. It is primarily the pathways connecting the two halves of the next part, which is called the cerebellum. The cerebellum, which means little brain in Latin, is in fact shaped like a small brain, and its primarily responsible for coordinating involuntary movement. It is believed that, when you learn complex motor tasks, the details are recorded in the cerebellum. The midbrain is, in human beings, the smallest part of the brain, it connects the midbrain to the forebrain, and contains several pathways important to hearing and vision. It is much larger in lower animals and in the human fetus.

The largest and, for psychologists, most interesting part of the brain is the forebrain. It starts with the thalamuswhich is practically in the center of your head. The thalamus is like a switching station, conducting signals form the body up to the relevant parts of the higher brain, and down from the brain to the lower brain and spinal cord. The fore brain though is complex enough to require its own chaptertwo, in fact, one for the limbic system, and one for the cerebrum.

The Peripheral Nervous System Sensory-Somatic Nervous System 12 pairs of cranial nerves and 31 pairs of spinal nerves

The Cranial Nerves Nerves I Olfactory II Optic Type sensory sensory Function Olfaction (smell) Vision (contains 38% of all the axons connecting to the brain) Eyelid and eyeball muscles Eyeball muscles Sensory: facial and mouth sensation Motor: chewing Eyeball movement Sensory: taste Motor: facial muscles and salivary glands Hearing and balance

III Oculomotor IV Trochlear V Trigeminal VI Abducens VII Facial VIII Auditory IX Glossopharyngeal X Vagus XI accessory XII Hypoglossal

motor motor mixed

motor mixed

sensory

mixed mixed

motor

Sensory: taste Motor: swallowing Main nerve of the parasympathetic nervous system (PNS) Swallowing; moving head and shoulder Tongue muscles

motor

The Spinal Nerves Thirty-one spinal nerves pass out on each side of the spinal cord through the intervertebral foramina. They correspond in name with the bones with which they are associated, thus Cervical (8), Dorsal (12), Lumbar (5), Sacral (5), Coccygeal (1).

Each nerve has two roots, an anterior and a posterior, which arises from two cornua, or horns, formed by projections backward and forward of the gray matter of the cord. The anterior root is composed of motor fibers, the posterior root of sensory fibers. On the posterior nerve roots there are swellings, calledganglia; immediately beyond these ganglia the two roots unite and form a nerve trunk, which is very short as it immediately divides into the anterior and posterior primary divisions. Each division contains fibers from both roots, so all the spinal nerves in their distribution are mixed nerves- that is; they contain both sensory and motor fibers. The motor or efferent fibers of the anterior root are distributed to the muscles, and cause their contractions. If the anterior root of the nerves supplying a certain part be injured, loss of power results in that part, though feeling remains. Autonomic Nervous System

The autonomic nervous systemis most important in two situations: emergency situations that causes stress and require us to fight or take flight, and nonemergency situations that allows us to rest and digest. The autonomic nervous system also acts in normal situations to maintain normal internal functions and works with the somatic nervous system. The autonomic nervous system consists of sensory neurons and motor neurons that run between the central nervous system (especially the hypothalamus and medulla oblongata) and various internal organs such as the heart, lungs, viscera and glands.

Circle of Willis An anterial circle at the base of the brain that is of critical importance. The circle of willisreceive all the blood that is pumped up the two internal carotid arteries that come up the front of the neck and that is pumped from the basilar artery formed by the union of the two vertebral arteries that come up the back of the neck. All the principal arteries that supply cerebral hemisphere of the brain branch off the circle of Willis. The circle of Willis is often not complete. Maximally, only a third of people enjoy a complete circle of Willis. This is of importance in the event that one of the major arteries (an internal carotid or vertebral artery) supplying the circle of Willis is occluded. The presence of a complete circle of Willis permits a continuing supply of blood to the entire brain and helps avert a stroke.

ASSESSMENT Subjective: Nahihirapan syang huminga as claimed by relative. Objective: Weak in appearance Dyspnea Use of accessory muscles Presence of crackles sound With O2 inhalation via nasal cannula. RR=28

DIAGNOSIS Impaired gas exchange related to ventilation perfusion imbalance as evidence by dyspnea.

PLANNING After 6 hours of nursing intervention the patient will able to demonstrate proper ventilation & adequate oxygenation.

INTERVENTION Place on a high fowlers position and provide airway adjuncts and suction as indicated.

RATIONALE To maintain airway.

EVALUATION After 6 hours of nursing intervention the patient was able to demonstrate proper ventilation & adequate oxygenation.

Note for the respiratory rate, depth and use of accessory muscles, and areas of adventitious breath sounds. Evaluate pulse oximetry & lung volumes.

To evaluate the degree of compromise.

To determine oxygenation and levels of CO2 retention and to asses respiratory insufficiency. To promote client expansion and drainage of secretions.

Encourage frequent position changes, deep breathing

exercise, and coughing exercises Provide supplemental oxygen at lowest concentration indicated by client symptoms/situat ion. To promote oxygenation.

Provide adequate rest and limit activities to within client tolerance.

Helps limit oxygen needs and consumption.

Provide psychological support, activelisten questions and concerns. Administer IV medications as prescribed.

To reduce anxiety.

To treat underlying condition.

ASSESSMENT Subjective: Tumataas ang BP nya as claimed by the relative. Objective: Lethargic Elevated BP of 200/110mmHg Weak and pale in appearance. Altered mental status.

DIAGNOSIS Ineffective cerebral tissue perfusion related to interruption of blood flow secondary to CVA.

PLANNING After 6 hours of nursing intervention the patient will demonstrate stable vital signs specifically BP.

INTERVENTION Monitor vital signs especially BP.

RATIONALE To know if the patients vital sign is stable.

EVALUATION After 6 hours of nursing intervention the patient demonstrate stable vital signs specifically BP.

Monitor heart rate and rhythm.

Changes in heart rate may occur because of brain damage. To determine whether the brainstem is intact.

Monitor neuro vital signs and evaluate pupils note, size, shape, equality, and light reactivity. Provide adequate rest period.

To minimize energy consumption.

Administer medications as prescribed.

To treat underlying condition.

ASSESSMENT Subjective: Hindi nya maigalaw ang kanyang katawanas claim by the relative. Objective: Conscious Facial grimace noted Right sided body weakness Irritability Limited ROM

DIAGNOSIS Impaired physical mobility r/t neuromuscul ar involvement as evidenced by right sided body weakness.

PLANNING After 6 hours of nursing intervention the patient will be able to increase the level of responsiven ess.

INTERVENTION Assist passive and active ROM exercises. Provide good skin care; gently massage pressure points after each position change. Provide safety measures and precautions.

RATIONALE To promote good body mechanics.

EVALUATION After 6 hours of nursing intervention the patient able to increase the level of responsiven ess.

Reduce the risk of skin the level of irritation or breakdown.

To avoid further injury.

ASSESSMENT Subjective: Objective: Conscious Difficulty of producing speech Inability to modulate speech Incomprehensible sounds.

DIAGNOSIS Impaired verbal response r/t neuromuscula r impairment as evidence by difficulty producing speech..

PLANNING After a series of nursing interventions the patient will able to establish method of communicati on in which needs can be expressed.

INTERVENTION Assess type or area of dysfunction.

RATIONALE It helps to determine area and degree of brain involvement. Provides for communicatio n of needs.

EVALUATION After a series of nursing interventions the patient was able to establish method of communicatio n in which needs can be expressed

Provide alternative methods of communication Anticipate and provide for clients needs. Encourage significant others to persists efforts to communicate with client. Respect clients preinjury capabilities & treat patients normally.

It helps to decrease frustration.

To reduce clients isolation and maintain sense of connectivenes s with family. It enables client to feel esteemed.

ASSESSMENT Subjective: Objective: Impaired ability to perform ADLs Poor hygiene With minimal sweating Weak and pale in appearance.

DIAGNOSIS Self care deficit r/t muscular impairment secondary to decreased strength and endurance as evidenced by impaired ability to perform ADLs.

PLANNING After a series of nursing interventions the patient will able to perform self care activities within level of own ability.

INTERVENTON Assess abilities and level of deficit for performing ADLs.

RATIONALE Aids in anticipating for meeting individual needs.

EVALUATION After a series of nursing interventions the patient able to perform self care activities within level of own ability.

Avoid doing things for client that client can do for self providing assistance as necessary.

To maintain self-esteem and promote recovery.

Maintain supportive firm attitude to the client. Provide physical and psychological support for the client.

To reduce clients isolation.

To reduce anxiety.

ASSESSMENT Subjective: Objective: Right sided body weakness Elevated BP of 200/110mmHg. With O2 inhalation via nasal cannula. Weak and pale in appearance.

DIAGNOSIS Activity intolerance r/t imbalanced oxygen supply as evidenced by right sided body weakness.

PLANNING After 6 hours of nursing intervention the patient will be able to participate willingly on necessary/desir ed activities.

INTERVENTIONS Assess the clients response to activity, note pulse rate and mark increase in BP after activity. Encourage progressive activity/self care when tolerated.

RATIONALE It helps in assessing physiologic response to the stress of activity.

EVALUATION After 6 hours of nursing intervention the patient was able to participate willingly on necessary/desir ed activities.

It helps to prevent a sudden increase in cardiac workload Encourage independence in performing activities.

Provide assistance as needed.

ASSESSMENT Subjective: Objective: Weak and pale in appearance Impairment of sensory & motor function. GCS of 8.

DIAGNOSIS Unilateral neglect r/t right hemiplegia from CVA of the left hemisphere as evidenced by GCS of 8.

PLANNING INTERVENTIONS After 6 hours Observe clients of nursing behavior & assess intervention sensory awareness the patient will perform self care Explore and within level of encourage ability/ verbalization of acknowledge feelings. presence of sensory perceptual impairment. Orient to environment as often and ensure adequate lighting and ventilation

RATIONALE To determine the extent of impairment. To identify meaning of loss and dysfunction to the client and impact. To improve clients interpretation of environmental stimuli. To promote tissue perfusion and prevent skin breakdown. To stimulate & clients awareness on the affected side

EVALUATION After 6 hours of nursing intervention the patient perform self care within level of ability/ acknowledg e presence of sensory perceptual impairment

Shift clients attention towards aff4ected side

Protect affected body parts from pressure injury and burns. Promote adequate rest period. To promote comfort and relaxation.

ASSESSMENT Subjective: Objective: Conscious Right sided body weakness anxious

DIAGNOSIS Disturbed body image r/t biophysical, psychosocial & cognitive or perceptual changes as evidenced by actual change in structure or function.

PLANNING After 6 hours of nursing intervention the patient will verbalize relief of anxiety & adaptation to actual or altered body image.

INTERVENTIONS Evaluate level of clients knowledge of anxiety r/t situation & observe emotional changes. Note signs of grieving / indicators of severe or prolonged depression. Provide opportunities for listening to concerns and questions. Encourage family members to treat client normally and not as invalid. Set limit on maladaptive behavior and assist to identify positive behaviors.

RATIONALE May indicate acceptance or nonacceptance of situation To evaluate need for counseling.

EVALUATION After 6 hours of nursing intervention the patient verbalize relief of anxiety & adaptation to actual or altered body image.

To reduce anxiety.

To decrease sense of isolation/ loneliness. To aid in recovery.

ASSESSMENT Subjective: Objective: Conscious Weak in appearance Absence of gag reflex Dyspnea GCS of 8.

DIAGNOSIS Risk for aspiration r/t entry of fluids into tracheobronchi al passages as evidenced by absence of gag reflex.

PLANNING After 4 hours of nursing intervention the patient will able to maintain a patent airway & clear lung sounds..

INTERVENTIONS Assess for clients LOC, awareness of surroundings & cognitive function. Place client on upright position.

RATIONALE Degree of impairment may increase clients risk of aspiration.

EVALUATION After 4 hours of nursing intervention the patient was able to demonstrate techniques to avoid aspiration

To prevent aspiration and promote chest expansion. To determine the signs of aspiration.

Monitor for respiratory rate, depth, & effort.

. Monitor lung sounds frequently. To determine the presence of secretions/ silent aspiration.

ASSESSMENT Subjective: Objective: Weak and pale in appearance. Limited ROM. Right side body weakness

DIAGNOSIS Risk for impaired skin integrity r/t physical immobiliz ation as evidenced by right sided body weakness.

PLANNING After 2 hours of nursing interventi on the patient will able to demonstr ates understa nding of plan to heal skin and prevent reinjury

INTERVENTION Monitor site of skin impairment at least once a day for color changes, redness, swelling, warmth, pain, or other signs of infection. Avoid position client on site of skin impairment. If consistent with overall client management goals, turn and position client at least every 2 hours Evaluate for use of specialty mattresses, beds

RATIONALE Systematic inspection can identify impending problems early.

Transfer client with care to protect against the adverse effects of external mechanical forces such as pressure, friction, and shear.

EVALUATION After 2 hours of nursing intervention the patient demonstrates understanding of plan to heal skin and prevent reinjury

Avoid massaging around the site of skin impairment and over bony prominences. Assess client's nutritional status

To reduce shear and friction, and use lift devices, pillows, foam wedges, and pressurereducing devices in the bed. Massage may lead to deep-tissue trauma

Inadequate nutritional intake places individuals at risk for skin injury.

ASSESSMENT Subjective: Objective: Right hemiplegia Weak and pale in appearance Immobilizati on GCS of 8

DIAGNOSIS Risk for injury related to right hemiplegia as evidenced by right sided body weakness.

PLANNING After 2 hours of nursing intervention the patient will be able to seek help to perform tasks that are beyond her capabilities.

INTERVENTION Monitor Vital signs.

RATIONALE To have baseline of data. To protect from falling out of bed.

EVALUATION Patient shall have seek help to perform task that are beyond her capabilities.

Provide assistance or safety measures.

Provide adequate rest period.

To prevent injury.

DRUG STUDY
Drug Name Generic name: Mannitol Action Indication Oliguria renal failure Toxic overdose Edema Increased intracranial pressure (ICP) Contraindic Dosage Side Effects ation Contraindicat 100 cc Dehydration ted with IV q6 hypersensitiv hours Anuria ity to drug Headache Dehydration Blurred vision N and V Nursing Consideration Monitor for: Vital signs Intake and output Pulmonary artery pressure Signs and symptoms of dehydration (e.g. poor skin turgor, dry skin, fever, thirst) Signs of electrolyte imbalance/deficit (e.g. muscular weakness, paresthesia, numbness, confusion, tingling sensation of extremity and excessive thirst) (for increase ICP) Neurologic status and intracranial pressure readings. (for increase IOP) Elevating eye pain or decreased visual acuity.

In the oliguric phase of acute renal failure, Mannitol increases osmotic pressure (pressure needed to Brand stop the absorption of Name:Osmitr something or osmosis) ol, Resectisol of the glumerular filtrate, thereby, promoting diuresis (treating the oliguric Classification: phase of renal failure) Osmotic and excretes toxic Diuretic materials (management for toxic overdose). It also elevates blood plasma osmolality thus, inhibiting the reabsorption of water and electrolytes (for relief of edema) and mobilizing fluids in the cerebral and ocular spaces (lowers intracranial or intraocular pressure).

Chest pain Pulmonary edema Thirst Tachycardia Hypokalemia Chronic renal failure

Drug Name Action Generic name: Isosorbide monobitrate isosorbide is the major metabolite mononitrate of isosorbidedinitrate. The mononitrate is not Brand Name: subject to first pass Monoket the metabolism. Relaxes vascular Classification: smooth muscle by stimulating production Coronary of intracellular cyclic vasodilator guanosine monophosphate. Dilation of postcapillary vessels decreases venous return to the heart due to pooling of blood; thus, LV end-diastolic pressure (preload) is reduced. Relaxation of arterioles results in a decreased systemic vascular resistance and arterial pressure (afterload).

Indication Acute anginal attacks; to prevent situations that may cause anginal attacks

Contraindication Dosage Contraindicated 25 ml IV in patients hypersensitive to nitrites, head trauma, cerebral hemorrhage or severe anemia.

Side Effects Hypotension Chest pain

Nursing Intervention Monitor vital signs Monitor client status for any occurance of any side effects. sAdvise patient to avoid alcoholic beverages; they may produce increased hypotension

Headache Dizziness Fatigue Diarrhea Nausea and vomiting

Drug Name Action GENERIC NAME: Reduces Diazepam anxiety by increasing or BRAND NAME: facilitating the inhibitory Valium neuritransmitt er activity of CLASSIFICATIO GABA. N: Produces Antianxiety agents, skeletal anticonvulsants, sedative/hyptonics, muscle skeletal muscle relaxation by relaxants (centrally inhibiting spinal acting) polysynaptic afferent pathways.

Indication Adjunct in the manageme nt of: Anxiety Preoperativ e sedation Conscious sedation - Provides light anesthesia and anterograd e amnesia - Treatment of status epilepticus/ uncontrolle d seizures - Skeletal muscle relaxant Manageme nt of the symptoms of alcohol withdrawal

Contraindication Dosage -Hypersensitivity 6 mg IV - Cross-sensitivity with other benzodiazepines may occurs Comatose patients Pre-existing CNS depression Uncontrolled severe painUse cautiously in: 1) Hepatic dysfunction 2) Severe renal impairment 3) History of suicide attempt or drug dependence

Side Effects CNS: dizziness drowsiness lethargy hangover headache depression EENT: blurred vision RESP: respiratory depression CV: hypotension GI: constipation diarrhea nausea vomiting DERM: rashes psychologica l dependence

Nursing Intervention Monitor BP, PR,RR prior to periodically throughout therapy and frequently during IVs therapy. - Assess IV site frequently during administration, diazepam may cause phlebitis and venous thrombosis. - Prolonged high-dose therapy may lead to psychological or physical dependence. Restrict amount of drug available to patient. Observe depressed patients closely for suicidal tendencies. - IM injections are painful and erratically absorbed. If IM route is used, inject deeply into deltoid muscle for maximum absorption. - Caution patient to avoid taking alcohol or other CNS depressants concurrently with this medication. - Effectiveness of therapy can be demonstrated by decrease anxiety level; control of seizures; decreased tremulousness.

Drug Name Generic Name: Ciprofloxacin Brand name: Quinosyn Classification: antibacterial

Action Interferes with DNA grynase and topoisomerase IV. DNA grynase is an enzyme needed for replication, ranscription, and repair of bacterial DNA. Topoimeserase iv plays an important role in the partitioning of chromosomal DNA during bacterial cell division.

Indication Contraindication Dosage Ciprofloxacin Hypersensitivity 200 mg is used to treat to drug. IV q12 infections of the skin, lungs, airways, bones, and joints caused by susceptible bac teria. Ciprofloxacin is also frequently used to treat urinaryinfectio nscaused by bacteria such asE. coli. Ciprofloxacin is effective in treating infectious diarrheas cause d by E. coli, Campylobacter jejuni , and Shigellabacteri a

Side Effects Nausea Vomiting Stomach pain Heartburn DiarrheaFeeling an urgent need to urinate Headache Hives Difficulty breathing or swallowing Hoarsenessor throat tightness

Nursing Intervention Instruct patient not to take ciprofloxacin with dairy products such as milk or yogurt, or with calciumfortified juice. He may eat or drink dairy products or calcium-fortified juice with a regular meal, but do not use them alone when taking ciprofloxacin. They could make the medication less effective. Tell patient to be careful if he plans to drive or do anything that requires him to be awake and alert. Instruct patient to take ciprofloxacin with a full glass of water (8 ounces).

Drug Name Generic paracetamol Brand Name: acetaminophen Classification: Analgesic antipyretic

Action

Indication

Contraindication

Dosage

Side Effects Skin rashes and other allergic reactions occur occasionally.

Nursing Intervention

name: Antipyretic: Reduces fever by acting directly on the hypothalamic heat-regulating center to cause vasodilation and sweating, which helps dissipate heat. Analgesic: Site and mechanism of action unclear

Paracetamol Hypersensitivity relieves pain acetaminophen and fever paracetamol. moderate intensity.

to 300 mg IV q4 or

Monitor for signs of symptoms of ypertoxocity even with moderate acetaminophen The rash is doses, especially in usually individuals with erythematous or poor nutrition. urticarial but sometimes more Give drug with serious and may food if be accompanied GI upset occurs by dug fever and mucosal lesion. Discontinue drug if hypersensitivity reactions occur.

Drug Name Generic Name:citicholin e sodium

Action

Indication

Contraindication

Dosage

It increases blood flow and O2 consumption Brand Name: in the brain. It is also Zynapse, involved in Somazine, the Cholinerve biosynthesis of lecithin.

Classification: CNS Stimulant, Peripheral Vasodilators, Cerebral Activators, Neurotropics.

Citicholine is Citicholine is 1 gram IV q8 indicated in CVD contraindicated with: in acute recovery phase in severe Any allergy or s/sx of hypersensitivity cerebrovascular to the drug insufficiency and Unconsciousnes in-cranial s traumatism and Brain surgery their sequellae. Citicholine in CVA, stimulates brain function.

Nursing Intervention Itching or hives, Monitor allergic swelling in face or reactions hands, chest tightness, tingling Hold drugs if in mouth and allergic reactions throat occur. Monitor signs vital

Side Effects

Assess neurologic status.

Drug name

Action

Indication To relieve bronchospasm associated with acute or chronic asthma, bronchitis, or other reversible obstructive airway diseases. Also used to prevent exerciseinduced bronchospasm.

Contraindication

Generic name:albuterol Synthetic and ipratropium sympathomimetic amine and Brand name: moderately Combivent, DuoNeb selective beta2adrenergic agonist with Classifications:autonomic comparatively nervous system agent; long action. Acts more prominently bronchodilator on beta2 receptors (particularly (respiratory smooth smooth muscles muscle relaxant) of bronchi, uterus, and vascular supply to skeletal muscles) than on beta1 (heart) receptors. Minimal or no effect on alphaadrenergic receptors. Inhibits histamine release by mast cells.

Nursing interventions Heart disease, 1 dose of Headache, nausea, Monitor vital high blood combivent nervousness, signs pressure, trouble epilepsy, sleeping,dizziness, Monitor for diabetes, drug dry mouth/throat, any occurrence allergies. This coughing, or of side effects medication runny nose should be used Do not allow only when clearly the patient to needed during drive pregnancy. Discuss the risk and benefits with your doctor. This drug may be excreted into breast milk

Dosage

Side effects