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UNCIANO COLLEGES INC.

ANTIPOLO CITY

CEREBROVASCULAR DISEASE
LLAGAS, JEMMILYN O. PERANDO,RACHEL ANNE L.

BACKGOUND OF THE STUDY

Cerebrovascular disease refers to 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. Atherosclerosis is one of the conditions that can cause cerebrovascular disease. During this process, 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 thick, waxy plaque. This plaque can limit, or completely obstruct, blood flow to the brain, causing a stroke, transient ischemic attacks, or dementia which may lead to a variety of other health complications.

The most common forms of cerebrovascular disease are cerebral thrombosis (40% of cases) and cerebral embolism (30%), followed by cerebral hemorrhage (20%).

Another form of cerebrovascular disease includes aneurysms. In females with defective collagen, the weak branching points of arteries give rise to protrusions with a very thin covering of endothelium that can tear to bleed easily with minimal rise of blood pressure. This can also occur with defective capillaries caused by tissue cholesterol deposition especially in hypertensive subjects with or without dyslipidemia. If bleeding occurs in this process, the resulting effect is a hemorrhagic stroke in the form of subarachnoid hemorrhage, intracerebral hemorrhage or both.

A fall in blood pressure during sleep can then lead to a marked reduction in blood flow in the narrowed blood vessels 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 hemorrhage. Cerebrovascular disease primarily affects people who are elderly or have a history of diabetes, smoking, or ischemic heart disease.

What are the symptoms of Cerebrovascular Disease? A symptom is something the patient senses and describes, while a sign is something other people, such as the doctor notice. For example, drowsiness may be a symptom while dilated pupils may be a sign. The signs and symptoms of cerebrovascular disease depend on the location of the hemorrhage, thrombus, or embolus and the extent of cerebral tissue affected. General signs and symptoms of a hemorrhagic or ischemic event include motor dysfunction, such as hemiplegia and hemiparesis.

What are the causes of Cerebrovascular Disease? Ischemic stroke occurs when a blood vessel that supplies blood to the brain is blocked by a blood clot. A clot may form in an artery that is already very narrow. This is called a thrombus. If it completely blocks the artery, it is called a thrombotic stroke. Also a clot may break off from somewhere in the body and travel up to the brain to block a smaller artery. This is called an embolism. It causes an embolic stroke. Ischemic strokes may also be caused by blood clots that form in the heart. These clots travel through the blood and can get stuck in the small arteries of the brain. This is known as a cerebral embolism.

Certain drugs and medical conditions can make your blood more likely to clot and raise your risk for ischemic stroke. A common cause of ischemic stroke in people under age 40 is carotid dissection, or a tear in the lining of the carotid artery. The tear lets blood flow between the layers of the carotid artery. This causes narrowing of the carotid artery that is not due to plaque buildup. Hemorrhagic stroke occurs when a blood vessel in part of the brain becomes weak and bursts open, causing blood to leak into the brain. Some people have defects in the blood vessels of the brain that make this more likely. The flow of blood that occurs after the blood vessel ruptures damages brain cells. Major modifiable risk factors include hypertension, smoking, obesity, and diabetes.

Diagnosing Cerebrovascular Disease In the physical examination, a doctor listens with the help of a stethoscope to detect abnormal sounds of blood flow (called bruit) on the neck. However, in severe cases of atherosclerosis, the bruit is less common.

A physician may look for specific neurological, motor and sensory deficits such as changes in vision or visual fields, abnormal reflexes, abnormal eye movements, muscle weakness, decreased sensation and other changes. A Cerebral Angiography, Vertebral Angiogram or Carotid Angiogram is also a possibility. In this radiological diagnostic method in which a catheter (a long narrow flexible tube) is inserted into the patient's artery with the help of a needle and guided through the main vessels of the abdomen and chest until it is placed in the arteries of the neck. The whole procedure is monitored with the help of a fluoroscope. X-ray pictures are taken after injecting a contrast dye in the neck with the help of the catheter.

A CAT scan is used to diagnose and detect hemorrhagic strokes, since blood, bone and brain tissue can be easily distinguished due to their difference in densities. It is important to note that damage from ischemic stroke cannot be detected by this scanning method. What are the treatment options for Cerebrovascular Disease? Blood platelet inhibitors such as Aspirin, Dipyridamole, Ticlopidine, Clopidogrel and Sulfinpyrazone are effective in reducing the risk for stroke. These drugs have been effective in treating patients with a history of stroke or patients at risk for a stroke event.

Carotid Endarterectomy is a procedure in which an incision is made into the carotid artery and the plaque removed with the help of a dissecting tool thus enabling normal blood flow. Then the artery is repaired with sutures or a graft. In Carotid Angioplasty and stenting a balloon tipped catheter is inserted into the artery and the balloon inflated to press against the plaque so as to flatten the plaque and reopen the artery. A tiny, slender metal mesh tube (stent) is fitted inside the carotid artery to improve the blood flow in the arteries blocked by plaque. The stent helps in preventing the artery from collapsing or closing up after the procedure is complete.

Preventing Cerebrovascular Disease Cerebrovascular disease can be best prevented by abiding by the following recommendations:quittings moking, regular physical exercise, eating heart healthy diet with low fat content, maintaining healthy weight or avoiding obesity, controlling blood pressure, controlling hypertension, avoiding anger or chronic stress and lowering blood cholesterol.

OBJECTIVES
GENERAL OBJECTIVE: Within hours of exposure at Unciano Medical Center, we, the 4th Year Nursing students of Unciano Colleges Antipolo City, aims to acquire the necessary knowledge, skills, and proper caring to a client in Intensive Care Unit with admitting diagnosis of to consider Cerebrovascular Disease.

SPECIFIC OBJECTIVE:
To be able to assess our clients condition and to identify the

clients health needs. To be able to communicate effectively with patients, families and healthcare providers, comprehending the value of teamwork compassion and clarity in the ICU setting To be able to recognize common clinical patterns and how they indicate impending cardiopulmonary arrest, circulatory shock, respiratory failure and need for resuscitation To be able to review the anatomy and physiology of the Cerebrovascular System To be able to formulate a nursing diagnosis. To be able to formulate a plan of care to our client with Cerebrovascular Disease. To be able to evaluate a patients response to critical care interventions to generate new hypotheses and diagnostic/treatment strategies.

PATIENTS PROFILE
Name Gender Age Address Religion Nationality Date of Admission Diagnosis Date/Time of Assessment R.A Male 44 yrs old Maragondon Real, Quezon Catholic Filipino October 27, 2012 T/C Cerebrovascular Disease November 6, 2012, at 4:00pm

NURSING HISTORY

Chief Complaint: unresponsiveness as stated at the clients data. Present Health History: R.A is 44 yr old, male. According to his data It was October 26, 2012 he started to camplain of headache, and October 26, 2012 he experience severe degree of weakness, and October 27, 2012 the patients was already unresponsive. The client is admitted in Christian General Hospital with GCS of 3 (E1M1V1) and with admitting diagnosis of T/C Intracranial Hemorrhage to r/o hypoglycemic shock but then he was referred by his doctor to Unciano Medical Center.

Upon admission to Unciano Medical Center, he was brought to the ER accompanied by his relatives with chief complaint or unresponsiveness. Vital Signs taken: BP: 170/80 CR: 149, RR: 25 T: 38.80C.Glasgow Coma Scale is 4 (E1M1V2). He was requested upon admission to Intensive Care Unit by Dr. Lazaro with a diagnosis of T/C Cerebrovascular Disease, and ordered Diagnostic Exams such as Urinalysis, Chemistry, CT-Scan, X-ray, and Hematology. and he was advise for some medication such as Pantoloc 40mg IV OD, Dilantin 100g NGT cap TID, Piptaz 2.25 IV q8 ANST(-), Totilac 125ml IV q4, and Paracetamol as needed, he has ongoing Intravenous Fluid PNSS 1L at right cephalic vein to run for 8 hours.

History of Past Illness:

As stated at the client data it was 2004 when patient R.A suffered in brain trauma and seizure because of vehicular accident.

REVIEW OF SYSTEM
Vital Signs: BP: 160/90, Pulse 97bpm, Respirations 24cpm, General: Around 2:00pm received the patient Mr. R.A in the Intensive Care Unit he is unconscious with GCS of 3 (E1M1V1). The patient is supported by mechanical ventilator and the size of his Endotracheal Tube is 7.5 mm, he has also Nasogastric Tube Inserted at his left nares. He has poor skin turgor, his skin was dry and his hair was not evenly distributed. His nails are long. We assess his vital signs, blood pressure 130/90mmhg, and pulse rate of 96bpm, respiratory rate of 24cpm and temperature of 36.1C.

Skin: cold and dry skin. HEENT Head: patient has a history of brain injury (2004) Eyes: Pupils anisocoria 3 mm, non reactive to light and Accommodation, sclera and conjunctiva normal.

Ears: Presence of cerumen


Nose: Nasogastric Tube French 22mm inserted to the left nares. Throat: Presence of Endotracheal tube french 7.5 mm. Tongue and gums are pale in color.

Chest: Abdomen: The abdomen is round. Sounds: Gurgling sound on the abdominal area. Extremities: Cyanosis is noted. Genital/Rectal: The patient has a foley catheter Neurological: The patient has a history of seizure (2004) We are not able to assess the patients Motor and reflexes because our patient is unconscious with GCS of 3 (E1M1V1). The CT scan reviewed cerebral infarction left.

ANATOMY AND PHYSIOLOGY OF THE CEREBROVASCULAR SYSTEM

The brain acts as a control center by receiving, interpreting, and directing sensory information throughout the body. There are three major divisions of the brain. They are the forebrain, the midbrain, and the hindbrain. The forebrain is responsible for a variety of functions including receiving and processing sensory information, thinking, perceiving, producing and understanding language, and controlling motor function. There are two major divisions of forebrain: the diencephalon and the telencephalon. The diencephalon contains structures such as the thalamus and hypothalamus which are responsible for such functions as motor control, relaying sensory information, and controlling autonomic functions. The telencephalon contains the largest part of the brain, the cerebrum. Most of the actual information processing in the brain takes place in the cerebral cortex.

The midbrain and the hindbrain together make up the brainstem. The midbrain is the portion of the brainstem that connects the hindbrain and the forebrain. This region of the brain is involved in auditory and visual responses as well as motor function. The hindbrain extends from the spinal cord and is composed of the metencephalon and myelencephalon. The metencephalon contains structures such as the pons and cerebellum. These regions assists in maintaining balance and equilibrium, movement coordination, and the conduction of sensory information. The myelencephalon is composed of the medulla oblongata which is responsible for controlling such autonomic functions as breathing, heart rate, and digestion. The brain contains various structures that have a multitude of functions. Below is a list of major structures of the brain and some of their functions.

Basal Ganglia

Involved in cognition and voluntary movement Diseases related to damages of this area are Parkinson's and Huntington's Brainstem Relays information between the peripheral nerves and spinal cord to the upper parts of the brain Consists of the midbrain, medulla oblongata, and the pons Broca's Area Speech production Understanding language Wernicke's Area Region of the brain where spoken language is understood.

Cerebellum

Controls movement coordination Maintains balance and equilibrium Cerebral Cortex Outer portion (1.5mm to 5mm) of the cerebrum Receives and processes sensory information Divided into cerebral cortex lobes Cerebral Cortex Lobes Frontal Lobes -involved with decision-making, problem solving, and planning Occipital Lobes-involved with vision and color recognition

Parietal Lobes - receives and processes sensory information

Temporal Lobes - involved with emotional responses,

memory, and speech Cerebrum Largest portion of the brain Consists of folded bulges called gyri that create deep furrows Corpus Callosum Thick band of fibers that connects the left and right brain hemispheres Cranial Nerves Twelve pairs of nerves that originate in the brain, exit the skull, and lead to the head, neck and torso Hippocampus - sends memories out to the appropriate part of the cerebral hemisphere for long-term storage and retrievs them when necessary Hypothalamus - directs a multitude of important functions such as body temperature, hunger, and homeostasis .

Olfactory Cortex - receives sensory information from the

olfactory bulb and is involved in the identification of odors Thalamus - mass of grey matter cells that relay sensory signals to and from the spinal cord and the cerebrum Medulla Oblongata - Lower part of the brainstem that helps to control autonomic functions Pituitary Gland Endocrine gland involved in homeostasis Regulates other endocrine glands

Pons

The pons is involved in several functions of the body including: Arousal Controlling Autonomic Functions Relaying Sensory Information Between the Cerebrum and Cerebellum Sleep A number of cranial nerve nuclei are present in the pons: mid-pons: The chief or pontine nucleus of the trigeminal nerve sensory nucleus (V) mid-pons: the motor nucleus for the trigeminal nerve (V) lower down in the pons: abducens nucleus (VI) lower down in the pons: facial nerve nucleus (VII) lower down in the pons: vestibulocochlear nuclei (vestibular nuclei and cochlear nuclei) (VIII)

The functions of these four nerves include sensory roles in hearing, equilibrium, and taste, and in facial sensations such as touch and pain; as well as motor roles in eye movement, facial expressions, chewing, swallowing, urination, and the secretion of saliva and tears. Blood is transported through the body via a continuous system of blood vessels. Arteries carry oxygenated blood away from the heart into capillaries supplying tissue cells. Veins collect the blood from the capillary bed and carry it back to the heart. The main purpose of blood flow through body tissues is to deliver oxygen and nutrients to and waste from the cells, exchange gas in the lungs, absorb nutrients from the digestive tract, and help forming urine in the kidneys. All the circulation besides the heart and the pulmonary circulation is called the systemic circulation

The major arteries are the vertebral and internal carotid arteries. The two posterior and single anterior communicating arteries form the circle of Willis, which equalises blood pressures in the brains anterior and posterior regions, and protects the brain from damage should one of the arteries become occluded. However, there is little communication between smaller arteries on the brains surface. Hence occlusion of these arteries usually results in localized tissue damage.

LABORATORY AND DIAGNOSTIC


CT SCAN REPORT 10/27/12 Examination: Plain axial cranial CT scan shows the ff: There is a large area of low attention density seen in the tempo parietal region with some hyperdense foci noted within it. Midline structures are displaced to the right. Left lateral ventricle is compressed. Left lateral cerebral cortical sulci appear effaced posterior fossa, petromastoids and osseous structures unremarkable.

Impression:
There are two conditions considered in the above findings due to absence of contrast study, one is hemorrhagic infarct with mass effect and the other is a neoplastic process. A follow-up study with contrast is suggested for further evaluation.

XRAY REPORT CHEST AP (SEMI SITTING) 10/27/12 Examination: There are no active lung parenchymal infiltrates noted. Heart is magnified in size. Aorta is tortuous. Hemi diaphragms costrophrenic sulci and visualized bones are intact. Endotracheal tube is noted in place.

Impression:

Atheromatous Aorta Magnified Cardiac Size cannot rule out true cardiomegaly.

John Anthony Layugan M.D, FPCR Radiologist

ARTERIAL BLOOD GAS


Normal Values Reference Range Results

10/27/12

Test Units
PH PaCO2 mmHg

Arterial
7.35-7.45 35-45

Venous
7.31-7.41 41-51 7.439 38.2 407 (-2)-(+3) 2

PaO2 mmHg 80-105 BEecf mmol/L (-2)-(+3)

HCO3 mmol/L 22-26


TCO2 mmol/L 23-27 SaO2% 95-98

23-28
24-29 95-98

25.9
27 100%

BLOOD GASES AMD ACID BASE ANALYSIS 10/31/12

Test PH PaCO2 PAO2 Stand Bicarb Base excess 02 Sat

Normal Range 7.35-7.45 35-45 80-105 22-26 +-2 95-98

Result 7.486 49.6mmHg 22 mmHg 37.4mmol/L 14mmol/L 100%

Hematology

10/27/12

Laboratory WBC Segmenter Lymphocytes RBC Hemoglobin Hematocrit

Result 22.3 0.88 0.12 6.06 173 0.52

Normal values 5-10x10^9L 0.40-0.60 0.20-0.40 6-1012 g/L 140-175 0.40-0.54

HEMATOLOGY

10/27/12

Examination

Result

Reference Values

Prothrombin Time
Patient Control %Activity INR APTT; Patient Control 15.2sec 13.8sec 90.8sec 1.11 34.0secs 36.2sec 24-39sec 12-15sec 11-16sec 70-100sec

HEMATOLOGY

11/4/12
Laboratory
WBC Segmenter Lymphocytes RBC Hemoglobin Hematocrit 17.4 0.87 0.13 4.09 136 0.379

Result

Normal values
5-10x10^9L 0.40-0.60 0.20-0.40 6-1012 g/L 140-175 0.40-0.54

CHEMISTRY

10/27/12
Test Name
Glucose BUN

Result
7.28 10.12

Unit
mmol/L mmol/L

Normal Value
3.89-5.83 2.9-8.20

Creatinine
Blood Uric Acid Cholesterol Triglycerides LDL

165.97
361.63 6.88 1.48 5.94

umol/L
umol/L mmol/L mmol/L mmol/L

51.8-123.7
200-413 3.12-5.46 0.40-1.85 2.04-4.95

HDL
GOT

0.27
29.99

mmol/L
U/L

0.75-1.82
3-33.0

CHEMISTRY

10/30/12

Examinations
Sodium, substc. Potassium, substc.

Result
148.2mmo/L 4.17mmo/L

Normal Values
135-148 3.5-5.3

DRUG STUDY

DRUG NAME

Generic Name: Pantoloc Brand Name : Pantoprazole Dosage: 40 mg TIV OD

CLASSIFICATI ON/ INDICATION Classification: Antacids, Antireflux Agents & Antiulcerants Indication: Symptomatic treatment of mild reflux esophagitis -Duodenal & gastric ulcers, reflux esophagitis -Duodenal & gastric ulcer -Eradication of H. pylori

ACTION

It inhibits specifically and doseproportionally H+,K+-ATPase, the enzyme which is responsible for gastric acid secretion in the parietal cells of the stomach. - thus inhibiting the proton pump and causing suppression of stimulated and basal gastric acid secretion after single and multiple intravenous and oral pantoprazole dosing

NURSING CONSIDERATI ON Hypersensitivity Possible Adverse Monitor to any Reaction: CBC, B12, component of the Diarrhea renal. LFTs formulation Abdominal List drugs lactation Pain prescribed Eructation to ensure Constipation none require Dyspepsia acidity to Gatroenterit metabolism is Report any kind of side effects Take as directed at the same time each day.

CONTRAINDIC ATION

ADVERSE REACTION

Drug Name

Classification/ Indication

Action

Generic Name: Phenytoin Sodium Brand Name: Dilantin Dosage: 100g Route: NGT Time: TID

Classification: Anticonvulsant Indication: Chronic epilepsy, especially of the tonic clonic pychomotor type.

Contraindication Adverse Reaction Acts in the Hypersensitivi Possible Adverse Reaction: motor cortex of ty to Ataxia the brain to hydantoins Drowsiness reduce the sprad Slurred exfoliative of electrical Speech dermatitis, discharges, Confusion sinis from the rapidly N&V Rach firing epileptic bradycardia Constipation foci in this area. second and Diarrhea third degree Gingival AV block. Hyperplasia

Nursing Consideration Use cautiously in patients with hepatic dysfunction, hypotension, myocardial infarction, diabetes, or respiratory depression, in elderly or debilitated patients and in those receiving other hydantoin derivatives. Use only clear solution for injection. A slight yellow color is acceptable. Dont refrigerate.

Drug Name Generic Name: Atenolol Brand Name: Tenormin Dosage: 50mg Route: Oral Time: OD

Classification/ Indication Classification: Beta adrenergic blocking agent Indication: For hypertension (either alone or with other antihypertensiv e such as diuretics).

Action

Contraindicatio n Contraindic ated with sinus bradycardia , second- or thirddegree heart block, cardiogenic shock, and CHF.

Adverse Reaction
Possible Adverse Reaction: Allergic reactions: Pharyngitis, erythematous rash, fever, sore throat, laryngospas m, respiratory distress CNS: Dizziness, vertigo, tinnitus, fatigue, emotional depression, paresthesias, sleep disturbances, hallucination s, disorientatio n, memory loss, slurred speech

Nursing Considerati on Assess VS, EKG & Lung Sounds Note history of diabetis, pulmonary disease or cardiac failure May aak symptoms of low blood sugar in those diabetics patient Report DOB

Blocks beta adrenergic receptors of the sympathetic nervous system in the heart and juxtaglomerular apparatus (kidney), thus decreasing the excitability of the heart, decreasing cardiac output and oxygen consumption, decreasing the release of renin from the kidney, and lowering BP.

Drug Name

Generic Name: Totilac Brand Name: Per 250 mL Na lactate (50%) 28.25g, KCL 0.075g, CaCl2 (100%) 0.05g Dosage: 125ml Route: IV Time: q4

Classification/ Action Indication Classification: Totilac is a Intravenous & neutral Other Sterile Solutions solution (pH Indication: = 7) Small volume fluid therapy for rapid containing restoration of intravascular vol (eg cations hemorrhagic & (sodium, dengue shock, burnt patient); prevention potassium, of hypovolemia & calcium) and maintaining stable hemodynamic status anions (peri-op condition); (chloride and as an alternative in lactate) that the treatment of metabolic acidosis & causes a electrolyte disorder moderate pH (hyponatremia); treatment for increase after tissue/peripheral edema; reduction of lactate is intracranial metabolized pressure in in the body traumatic brain injury; source of alternative energy substrate during cell restoration postischemia.

Contraindication

Adverse Reaction

Nursing Consideration

Severe hypernatre mia (plasma Na >155 mmol/L), metabolic alkalosis (pH >7.5) & renal failure w/ anuria.

Possible Adverse Reaction: Febrile response, infection at site of injection venous thrombosis or phlebitis extending from site of injection extravasati ons, hypervole mia, hypernatre mia, hypochlore mia metabolic alkalosis

Drug Name

Classification/ Indication Classification: CNS Drugs Indication: Acute and recovery phase of cerebral infarction (eg, ischemia due to stroke). Cognitive dysfunction due to degenerative (ie, Alzheimer's disease) and cerebrovascular disease. Cerebral insufficiency (eg, dizziness, memory loss, poor concentration, disorientation) due to head trauma or brain injury.

Action Citicoline is a complex organic molecule that functions as an intermediate in the biosynthesis of cell membrane phospholipids. It is also known as CDP-choline or cytidine diphosphate choline (cytidine 5'diphosphocholine) . CDP-choline belongs to the group of biomolecules in living systems known as nucleotides that play important roles in cellular metabolism

Contraindication

Adverse Reaction

Nursing Consideration

Generic Name: Somazine Brand Name: Citicoline Dosage: 5ml Route: NGT Time: BID

Patients with hypertonia of the parasympath etic nervous system.

Possible Adverse Reaction: Gastrointest inal disorders (ie, stomach pain, diarrhea). Vascular side effects (ie, hypotensio n, tachycardia, bradycardia ).

Somazin e must not administe r together with medicine s containin g meclophe nexate.

Drug Name

Classification/ Indication Classification: Generic Analgesics ( Name: Paracetamol Non-opioid) Antipyretics Indication: Brand Name: Temporary Aeknil relief of pain and discomfort Dosage: from headache, fever, cold, flu, 300m minor muscular Route: TIV aches, Time: PRN overexertion, menstrual cramps, toothache, minor arthritic pain.

Action Paracetamol may cause analgesia by inhibiting CNS prostaglandin synthesis. The mechanism of morphine is believed to involve decreased permeability of the cell membrane to sodium, which results in diminished transmission of pain impulses therefore analgesia.

Contraindicati on Barbiturates, carbamapezine, hydantoins, isoniazid, rifampin, sulfinpyrazone: May reduce therapeutic effect and enhance hepatotoxic effects of acetaminophen with high doses or long-term use of these drugs. Avoid use together.

Adverse Reaction Possible Adverse Reaction: Hematologi c: Hemolytic anemia, leukopenia, neutropenia , pancytopen ia, Thrombocy topenia. Hepatic: liver damage, jaundice Metabolic: hypoglyce mia Skin: rash, urticuria

Nursing Consideration Assess patients pain or temperature before therapy and regularly thereafter. Asses patients drug history and calculate total daily dosage accordingly . Be alert for signs of reactions and drug interactions .

Drug Name Generic Name: Digoxin Brand Name: Lanoxin Dosage: 0.25mg tab Route: NGT Time: OD

Classification/ Action Indication Classification: Antiarrhythmics, inotropics Indication: Cardiac failure accompanied by atrial fibrillation; management of chronic cardiac failure where systolic dysfunction or ventricular dilatation is dominant; management of certain supraventricular arrhythmias, particularly chronic atrial flutter & fibrillation.

Nursing Consideration Increases the force Intermittent Possible Adverse Monitor of myocardial complete heart Reaction: apical pulse contraction. block or 2nd CNS: before Prolongs degree AV block disturbances, administering refractory period esp if there is a dizziness; . of the AV node. history of Stokesvisual Monitor Decreases Adams attacks; disturbances blood conduction arrhythmia caused (blurred or pressure through the SA by cardiac yellowish periodically and AV nodes. glycoside vision); in patients Increased cardiac intoxication, arrhythmia, receiving IV output (positive supraventricular conduction dogoxin. inotropic effect) arrhythmia caused disturbances, Monitor and slowing of the by Wolffbigeminy, intake and heart rate Parkinson-White trigeminy, PR output ratios (negative syndrome; prolongation, and daily chronotropic ventricular sinus weights. effect). tachycardia or bradycardia; fibrillation; nausea, hypertrophic vomiting, obstructive diarrhea; cardiomyopathy. urticarial or Hypersensitivity scarlatinifor to other digitalis m w/ glycosides. eosinophilia.

Contraindicati Adverse on Reaction

Drug Name

Classification/ Indication Classification: Diuretics, Miscellaneous Indication: Promotion of diuresis in the prevention or treatment of the oliguric phase of acute renal failure before irreversible renal failure becomes established. Reduction of intracranial pressure and brain mass. Reduction of high intraocular pressure when the pressure cannot be lowered by other means.

Action

Contraindication Adverse Reaction

Generic Name: Mannitol Brand name: Osmitrol, Resctisol

Mannitol increases urinary output by inhibiting tubular reabsorption of water and electrolytes. It raises the osmotic pressure of the plasma allowing water to be drawn out of body tissues.

Pulmonary congestion or oedema; intracranial bleeding; CHF; metabolic oedema with abnormal capillary fragility; anuria due to severe renal disease; severe dehydration

Possible Adverse Reaction: Fluid and electrolyte imbalance; acidosis (with high doses). Nausea, vomiting, thirst; headache, dizziness, convulsions, chills, fever; tachycardia, chest pain; blurred vision; urticaria and hypotension or hypertension; acute renal failure; skin necrosis; thrombophloebitis .

Nursing Consideration The Cardiovascular status of the patient should be Carefully evaluated before Rapidly Administering mannitol since sudden expansion of the extracellular fluid may lead to Fulminatingc ongestive heart failure.

Drug Name

Classification/ Indication

Action

Contraindication

Adverse Reaction

Nursing Consideration

Generic Name: Piperacilin Tazobactam Brand Name: Piptaz

Dosage: 2.25mg Route: TIV Time: q8

Classification: Treatment of Piperacillin and infections in the enzyme lower inhibitor respiratory tract Ex: severe Indication: communityBelongs to the aquired class of pneumonia & penicillin healthcare combinations, pneumonia; including beta- uncomplicated lactamase & complicated inhibitors. Used skin & skin in the systemic structure treatment of infections; infections. intra-abdominal infections w/ peritonitis.

Hypersensiti vity to penicillins, cephalospori ns & lactam inhibitors

Possible Adverse Reaction: Hypertensio n, chest pain, edema, dyspnea, hypotension, Tachycardia, bradycardia, heart failure.

Piptaz should not be added to blood products or albumin hydrolysates and should not be mixed with other drugs in a syringe or infusion bottle due to possible problems with compatibility. Piptaz is not chemically stable in solutions that contain only sodium bicarbonate and solutions that significantly alter pH. Lactated Ringer's Solution is not compatible with Piptaz.

NURSING CARE PLAN

Nursing Cues

Nursing Diagnosis

Goals of Care

Intervention/ Rationale

Evaluation

Objective: Hgb-136 Hct-.379 Lymphocyte 0.13 Fever Presence Endotracheal Tube and Nasogastric Tube

Risk for infection related to inadequate secondary defense and to a site for organism invasion secondary to intubation. Objective: Hgb-136 Hct-.379 Lymphocyte 0.13 Fever Endotracheal Tube NGT

Within 3 hours of nursing intervention the patient will remains free of infection, as evidenced by normal vital signs, and absence of purulent drainage from wounds, and tubes.

Independent: 1. Wash hands and teach other caregivers to wash hands before contact with patient, and between procedures with patient.

After 3 hours of nursing intervention the patient was remains free of infection, as evidenced by normal vital signs, and absence of 2. Place patient in purulent protective isolation drainage from if patient is at very wounds, and high risk. tubes. Rationale:
Protective isolation is established to protect the person at risk from pathogens.

3. Limit visitors. Rationale: To reduce the number of organisms in patient's environment and restrict visitation by individuals with any type of infection to reduce the transmission of pathogens to the patient at risk for infection. The most common modes of transmission are by direct contact) and by droplet. 4.Monitor use or overuse of antimicrobial therapy. 5.Administer the Paracetamol 300mg. Rationale: To decrease fever.

Dependent:
Administer medication as ordered: Cefuroxime 750mg TIV Piptaz 2.25mg TIV q8

Nursing Cues

Nursing Diagnosis

Goals of Care

Intervention/ Rationale

Evaluation

Objective: T: 37.9

Ineffective thermoregulati on related to damage to hypothalamic center. Objective: 37.9

After 1 hourof 1.Environme nt can be nursing adjusted intervention the depending on body temperature the patients of the patient will condition. decreased. Rationale: To
promote a normal body temperature 2. Remove clothes at blankets over the patients. Rationale: To lessen the heat. 3. Administer Paracetamol as needed. Rationale: To reduced fever

After 1 hour minutes of nursing intervention the body temperature of the patient was decreased from 37.9 to 36.1.

4. Provide Ice bath.

Rationale: To increase surface cooling


5. Frequent temperature monitoring.

Rationale: To assess the patients response to therapy, to prevent an excessive decreased in temperature.

Nursing Cues

Nursing Diagnosis

Goals of Care

Intervention/ Rationale

Evaluation

Objective: Unconsciou s 2 weeks bedridden dry skin Poor skin turgor

Risk for Impaired Skin Integrity r/t prolonged immobility

After 1 hour of nursing intervention the patients skin will not show dryness or worsening of skin breakdown such as redness or swelling.

1.Reposition the client every 2 Hours Rationale: to prevent pressure to certain parts of the body.

After 1 hour of nursing intervention patients skin was not show dryness or worsening of skin breakdown such as redness or swelling.

general condition of skin. Rationale: Healthy skin varies from individual to individual, but should have good turgor, feel warm and dry to the touch, be free of impairment, and have quick capillary refill (<6 seconds). 3. Observe skin for areas of redness, breakdown. Rationale: Early detection of problem areas allows for additional intervention to prevent complications/promote healing. 4. Provide Bed bathing. Rationale: To prevent excessive dryness of the skin.

2. Assess

Nursing Cues

Nursing Diagnosis

Goals of Care

Intervention/ Rationale

Evaluation

Objective:

Risk for Unconscious aspiration GCS: 3 related to (E1M1V1) reduce level of Presence of consciousness endotracheal secondary to:

After 1 hour of nursing intervention the patient's risk of aspiration will decreased as a tube and tube Presence of result of feedings endotracheal ongoing (NGT) tube and tube assessment and feedings early (NGT) intervention.
Unconscious GCS: 3 (E1M1V1)

1. Monitor level of consciousnss. Rationale: A decreased level of consciousness is a prime risk factor for aspiration.

2. Assess cough and gag reflex. Rationale: A depressed cough or gag reflex increases the risk of aspiration.

After 1 hour of nursing intervention the patient's risk of aspiration is decreased as a result of ongoing assessment and early intervention.

3. Keep suction setup available and use as needed

Rationale: To maintain a patent airway.


4. Position patients who have a decreased level of consciousness on their side.

Rationale: To protect the airway. Proper positioning can decrease the risk of aspiration. Comatose patients need frequent turning to facilitate drainage of secretions.
5. Check placement of Nasogastric tube before feeding.

Rationale: A displaced tube may erroneously deliver tube feeding into the airway.

Nursing Cues

Nursing Diagnosis

Goals of Care

Intervention/ Rationale

Evaluation

Objective: Unconscious GCS: 3 (E1M1V1)

Ineffective Airway clearance related to altered level of consciousness. Unconscious GCS: 3 (E1M1V1)

After 1 hour of nursing intervention the patient must be monitor to maintain patent airway and ensure ventilation.

1. Elevate the head of the bed 30 Degrees


Rationale: To prevent Aspiration. 2.Suctioning should also be done. Rationale: To remove secretions.

After 1 hour of nursing intervention the patient's risk of aspiration is decreased as a result of ongoing assessment and early intervention

4. Auscultate the chest every 8 hours

Rationale: To detect adventitious breath sounds.


5. Position the patient in lateral or semi prone position.

Rationale: To promote drainage of secretions

EVALUATION
GENERAL OBJECTIVES: After 32 hours of exposure at Unciano Medical Center, we, the 4th Year Nursing students of Unciano Colleges Antipolo City, aims to acquire the necessary knowledge, skills, and proper caring to a client in Intensive Care Unit with admitting diagnosis of Cerebrovascular Disease.

SPECIFIC OBJECTIVE:
We are able to assess our clients condition and to identify

the clients health needs. We are able communicate effectively with patients, families and healthcare providers, comprehending the value of teamwork compassion and clarity in the ICU setting We are able to recognize common clinical patterns and how they indicate impending cardiopulmonary arrest, circulatory shock, respiratory failure and need for resuscitation We are able to review the anatomy and physiology of the Cerebrovascular System We are able to formulate a nursing diagnosis. We are able to formulate a plan of care to our client with Cerebrovascular Disease. We are able to evaluate a patients response to critical care interventions to generate new hypotheses and diagnostic/treatment strategies.

THANK YOU !