Biographic Data: Patient X was admitted on September 21, 2010 at 11:00 pm at PDMMMC. Patient X who is male, 67 years of age, Married, Roman Catholic, Filipino is presently residing at Caloocan City. Nursing Health History: Chief Complaint: PTA patient suddenly developed LOC; he then noted weakness of his left side of the body.
Past illness history: As verbalized by his wife he have no past history illness. This was the first he admitted to the hospital.
Family history illness: Hereditary of both side’s mother and father (+) hypertension
Present illness history: Patient was diagnosed (+) Hypertension and (+) DM
Lifestyle: (+) Smoking (1 ½ pack of cigarettes a day) (+) drinking (beer twice a day, Moring and evening)
Gordon’s Functional Health Patterns
Nutritional-Metabolic Pattern
Elimination Pattern
Cognitive-Perceptual pattern
Activity-Exercise pattern
Sleep-Rest pattern
Past History - Usual eating pattern “3 meals a day - Prepares to eat more on vegetables and high sodium(dried sodium(dried fish,grilled pork) and fatty foods(balot, nilagang baka,chicaron,crispy pata)
Present History - Ostiorized feeding through NGT with low salt low fat diet.
- Has no problem on elimination - Urine output of approximately 1,300ml per day
- With Foley catheter connected to urine bag with dark yellow urine output(1,100ml) - Involuntary passage of stool characterized by loose, liquid stool elimination(150mg) - Changes diaper 4 times a day - PTA, disoriented to time and place - Difficulty of breathing - slurring of speech - Inability to move right half/side of the body -Complete bed rest
- Responds appropriately to verbal and physical stimuli
- No particular habits of exercise - Usually consumes 1 ½ packs of cigarette per day - Drinks regularly 2 bottles of liquor - Irregular sleep when at home consumes only 5-6 hours of sleep - Inadequate rest
- Fell asleep for 1-2 hours - When awake, appears agitated and restless due to administration of nasal cannula
Physical Assessment Normal Findings
Actual Findings
Remarks
SKIN Color and pigmentation Moisture Temperature Mobility and turgor
Light to deep brown
Pallor Hot and Dry
Moist
The skin slowly The skin springs returns back to its back to its previous previous state after state after being being pinched pinched
Impaired Circulation Fever Old Age
NAILS Nail bed color
Pink
Pale
Impaired Circulation
Capillary refill
capillary refill (13secs)
delayed capillary refill (4 secs)
Light to deep brown
Pale
Impaired Circulation
Pink conjunctiva
Pale palpebral conjunctivae
Decreased tissue perfusion
Impaired Circulation
FACE Skin color
EYES Conjunctiva
MOUTH & PHARYNX
Lips Color
Pink
Pale
Poor
Moisture
Moist
Dry
Circulation Poor Hydration
Tongue Position
Left lateral(slurred speech)
Left lateral position Slurred speech
abnormal
Teeth
No cavities
Some Teeth Missing (smoker)Some with cavities
Poor Oral Care
halitosis
NECK Range of movements
Smooth movements without discomfort Symmetric and at midline position
Restricted movements with discomfort Symmetric and at midline position
Due to Muscle Weakness and numbness
Rales, crackles sounds
Due to pneumonia
THORAX Lungs
No tenderness No adventitious sound
HEART Rate
Normal(60-100)
Abnormal(120bpm)
Increased rate due to Infection
UPPER AND LOWER EXTREMITIES
NORMAL FINDING
ACTUAL FINDING
REMARKS
SKIN COLOR
Light to deep brown
Bluish discoloration
Impaired circulation
LABORATORY EXAMINATION HEMATOLOGY SEPTEMBER 22, 2010
RESULT
REFERENCE
REMARKS
HEMATOCRIT
0.37
0.40-0.51
Blood loss
HEMOGLOBIN
131
135-180g/L
Blood loss
RBC COUNT
4.11
50-6.5x10-12g/L
Blood loss
WBC COUNT
12
4.5-11.0x10g/L
Infection
NEUTROPHILS
0.85
0.50-0.70
Infection
LYMPHOCYTES
0.15
0.20-0.40
infection
SEPTEMBER 23, 2010
RESULT
REFERENCE
WBC
13
4.5-11.0x10g/L
RBC
3.5
50-6.5x10-12g/L
REMARKS Increase WBC Anemia
SEPTEMBER 23, 2010
CHEMISTRY
RESULT
UNIT
REMARKS
SODIUM (ISF)
140.50mmol/L
135-148
Normal
POTASSIUM (IST)
3.36mmol/L
3.50-5.30
Hypokalemia
HEMOGLUCOSE TEST SEPTEMBER 22, 2010 6:00PM (before meal)
RESULT
REFERENCE
REMARKS
129mg/dl
70-110mg/dl
Hyperglycemic
SEPTEMBER 27, 2010 12 PM(before meal)
RESULT
REFERENCE
REMARKS
151mg/dl
70-110mg/dl
Hyperglycaemic
LABORATORY EXAM CHEST X-RAY RESULT:
RIGHT POSTERIOR INFILTRATES PNEUMONIA SLIGHT LEFT VENTRICULAR CARDIOMEGALY BONY THORAX IS INTACT
CT SCAN ACUTE INTRAPARENCHYMAL HEMATOMA IN THE LEFT BASAL GANGLIA
MEDICATION Brand Name/Gen eric Name
Dosa ge for Patie nt
CEFTRIAXO 2gra NE ms as initial Cephalosp dose orin, third then generatio OD (-) ANST.
Action
Inhibit cell wall synthesis promoting osmotic instability visually bactericidal
Indication
Contraindic ation
Lower Hypersensitiv respiratory e to drug tract infections, due to staphylococcu s aureus and stertococcus pnuemonae.
Adverse Effect
Diarrhea, Rash, eosinophilia, nausea, pain/indurati on tenderness warmth at injection site
Nursing Responsibiliti es
Do not mix drugs with other antibiotics. Maintain dosage for at least 2 days after symptoms have disappeared.
Brand Name/Generic Name
Dosag e for Patie nt
Action
TORVASTATIN
80mg / tab
Competitiv ely inhibits AMG – coA reductase, this enzymes catalyzes the early rate – limiting step in the synthesis of cholesterol. Thus, cholesterol synthesis is inhibited or decreased.
ntihyperlipide ic MG – coA eductase nhibitor
½ tab OD @ HS.
Brand Name/Generic Name
CLINDAMYCIN Antibiotic, Lincosamide
Dosa ge for Patie nt 300 mg 1 tab TID
Indication
Adjunct to diet to decrease elevated total and LDL cholesterol, apo B and triglyceride is primary hypercholesterole mia.
Action
Suppresse s protein synthesis by micro organisms by binding to ribosomes and preventing peptide
Indication
Serious infection caused by susceptible strains of streptococci, pneumococci , stapyloccoci and anaerobic bacteria.
Contraindicat ion
Active liver disease or unexplained persistently high LFT’s. Use with grapefruit juice.
Adverse Effect
Nursing Responsibiliti es
Headache, Paresthesi a, Asthenia, Insomnia
Give as a single dose anytime with or without food.
Determine lipid levels within 2-4 weeks. Adjust dosage accordingly.
Contraindica tion
Adverse Effect
Nursing Responsibi lities
Hypersensitivi ty to either clindamycin or lincomycin.
CV: hypoten sion,
If significant diarrhea occurs and report to physician.
Thromb ophlebit is
bond formation. It’s both bacteriost atic and bacterioci dal.
Brand Name/Gene ric Name
Dosag e for Patie nt
Action
Indication
Contraindicat ion
Advers e Effect
Nursing Responsibiliti es
LOSARTAN
50 mg / tab OD
Inhibits vasoconstricti on and aldosteron secreting action of angiotensine to receptor on the surface of vascular smooth muscle of other cell
Antihypertensi ve, alone or in combination with other antihypertensi ve drugs.
Contraindicate d to patient hypertensive to drug
CV: Angina pectoris, vasculiti s.
No initial dosage adjustment is needed for the elderly or for those with renal impairment, including those on dialysis.
Anti hypertensiv e angiotensin II receptor blocker.
Reduce risk of stroke in clients with hypertension and left ventricular hypertrophy
Brand Name/Gene ric Name
Dosag e for Patie nt
Action
Indicatio n
MANNITOL
100 cc / IV every 6 hours
Increases the osmolarity of the glomerula r filtrate, which decreases the reabsorpti on of water and increases excretion of sodium and chloride. It also increases the osmolarity of the plasma, which causes enhanced flow of water from tissues into the interstitial fluid and plasma
Decrease ICP and cerebral edema by decreasi ng brain mass.
Diuretic, osmotic
Brand Name/Gener
Dosage for
Action
Contraindicat ion
Anuria, pulmonary edema, severe dehydration, active intracranial bleeding, except during To craniotomy, promote progressive urinary renal damage excretio following n of toxic mannitol substanc therapy e.
Indication
Adverse Effect
Nursing Responsibiliti es
CV: edema, hypo/hypertensi on, increased heart rate, angina like chest pain, CHF, Trombophlebiti s
Use a filter with concentrated mannitol (15%, 20%, and 25%)
Contraindicati on
Concentratio n > 15% may crystallize. Do not add t other IV solutions or mix with medications
Adverse Effect
Nursing Responsibili
ic Name RANITIDINE Histamine H2 receptor blocking drug
Patient 50 mg / IV every 8 hours
Brand Name/Gene ric Name
Dosag e for Patie nt
SALBUTAMOL Anti-asthma
1 neb every 6 hours
ties Competeti Treatment vely of inhibits endoscopical action of ly diagnosd histamine erosive on the H2 esophagitis at the and for receptor maintenanc sites of e of healing parietal of erosive cells esophagitis. decreasin g gastric IV – Prevent acid paclitaxel secretion. hypersensiti vity; reduce the incidence of GI hemorrhage associated with stress related ulcers
Cirrhosis of the liver, impaired renal or hepatic function
Action
Indication
Contraindicat ion
Relaxes bronchial uterine and vascular smooth muscle by stimulati ng Beta 2 receptor.
Prevent/trea t bronchospas m in patient with reversible obstructive airway disease.
Hypersensitivit y
Headache
The premixed infection does Abdominal not require pain dilution; give Constipation by SLOW IV drip over 15 – 20 minutes. Do not introduce additives into the solution. Undiluted ranitidine injection tends to manifest a yellow color that may intensify over time without adversely potency
Adverse Effect
Precaution: Hyperthyroidi sm DM Cardiovascula r disease Adverse reaction: Fine tremor of skeletal muscle
Nursing Responsibiliti es Assess condition before therapy and reassess regularly thereafter to monitor drug effectiveness.
feeling oftension a compensary small increase in heart rate, headache, muscle cramps
Brand Name/Generi c Name
Dosag e for Patie nt
Action
Indicati on
Contraindicati on
Adverse Effect
Nursing Responsibilitie s
CITICOLINE
1g/ IV every 12 hours.
Citicoline is an internuerona l communicati on enhancer. It increases the neuro transmission levels because it favors the synthesis and production speed of dopamine in the stratum.
CVD in acute and recover y phase.
Parasympath etic hypertonia
Insomni a, headach e.
Somazine must not be administered along with medicanents containing medophenoxat e.
CNS Stimulant
Brand Name/Generic Name
Dosag e for Patie
Action
Indicati on
Contraindicat ion
Advers e Effect
Nursing Responsibilities
nt Paracetamol
500mg q4
(Biogesic)
Unknown. thought to produce analgesia by bocking pain impulses probably by inhibiting synthesis of prostaglandi n in the CNS or other at substance t
Mild pain or fever
Hypersensitive to drug
REVIEW OF SYSTEM •
Nervous system
1. Brain -left brain paralysis ← -speech problem ← -blurring of vision ← -level of consciousness(decrease) 2. Nerves - Damage in the cranial nerves particularly in Optic Nerves •
Blurred vision
, Trigeminal Nerves •
Numbness of sensation
Facial Nerves •
, Vagus Nerves
Loss of motor activity
Rash
Use cautiously in patient with history of chronic alcohol use because of hepatotoxicity.
Accessory Nerves •
,
Hypoglossal Nerves •
Slurring of speech
- Loss of sensation in right upper and lower extremities or unilateral or bilateral part of the body 3. Spinal Cord -loss of sensation and motor -loss of homeostasis -paralysis
•
Respiratory System 1. Lungs - Pneumonia - Chest pain - cough with phlegm - rales or crackles sound 2. Diaphragm - Difficulty of breathing
•
Musculoskeletal System 1. Muscles -weakness of face muscles -loss of motor movement -Weakness of body muscles 2. Bones -activity intolerance -immobility
•
Circulatory System •
Blood -blood clot -increase blood pressure
•
Digestive system •
Salivary glands -difficulty of swallowing/chewing - Incapable of eating by mouth
ANATOMY & PHYSIOLOGY
←
PATHOPHYSIOLOGY
Sign and symptoms: - Flaccid paralysis - Spastic paralysis - Coma - LOC •
-
Frontal: Contralateral muscle weakness or paralysis
- Sensory loss in legs •
Middle cerebral artery
Complication: Pneumonia Aspiration Constipation Contractures related to paralysis
