VELEZ COLLEGE – NURSING

F. RAMOS ST., CEBU CITY

A C.A.R. ON B.P., 69 Y.O., FEMALE, DIAGNOSED WITH RIGHT THALAMIC INFARCTION AND HYPERTENSIVE ATHEROSCLEROTIC CARDIOVASCULAR DISEASE

SUBMITTED BY:

Cinderella L. Pacheco
BSN 3B
 Hypertensive Atherosclerotic Cardiovascular Disease Causes
High blood pressure increases the pressure in blood vessels. As the heart pumps against this
 Hypertensive Cardiovascular Disease is a medical term for enlargement of the heart. pressure, it must work harder.
Hypertensive cardiovascular disease also known as hypertensive heart disease occurs Over time, this causes the heart muscle to thicken. The heart must work harder to pump blood
due to the complication of hypertension or high blood pressure. In this condition the out to the body. Without treatment, symptoms of congestive heart failure may develop.
workload of the heart is increased manifold and with time this causes the heart High blood pressure can cause ischemic heart disease because the thicker heart muscle needs
muscles to thicken. The heart continues pumping blood against this increased an increased supply of oxygen.
pressure and over a period of time the left ventricle of the heart enlarges and this in High blood pressure also contributes to thickening of the blood vessel walls. This may worsen
turn causes the blood pumped by heart to reduce. atherosclerosis (increased cholesterol deposits in the blood vessels). This also increases the
 Attributed to the build-up of fat deposits, which clog up the heart arteries, which risk of heart attacks and stroke.
limits the blood and oxygen flow and supply to the heart. Possible Complications
 Angina
Classifications of Hypertension  Arrhythmias
Category Systolic Diastolic  Heart attack
Optimal <120 <80  Heart failure
Pre-hypertensive 120-139 80-89  Stroke
Hypertensive >or=140 >or=90  Sudden death
 Stage 1 140-159 90-99
Treatment
 Stage 2 >or=160 >or=100
The primary aim of any treatment in hypertensive cardiovascular disease is:
 Reduction of blood pressure and then eventual control of the heart disease
 The line of treatment may include: beta blockers, angiotensin converting enzyme
inhibitors (ACE), calcium channel blockers, diuretics
Symptoms and signs
 Fatigue
NURSING INTERVENTIONS:
 Cardiomegaly
 Irregular pulse or Palpitations
 Assess the blood pressure
 Swelling of feet and ankles
 Educate clients on their target blood pressure and the importance of achieving and
 Weight gain
maintaining this target.
 Nausea
 Identify lifestyle factors that may influence hypertension management
 Shortness of breath
 Counsel clients with hypertension to limit their dietary intake of sodium to the
 Difficulty sleeping flat in bed
recommended quantity of 65-100 mmol/day.
 Bloating and abdominal pain
 Assess clients’ weight, Body Mass Index (BMI) and waist circumference.
 Greater need to urinate at night
 Advocate that clients with a BMI greater than or equal to 25 and a waist
 Altered mentation (in severe cases) circumference over 102 cm (men) and 88 cm (women) consider weight reduction
 myocardial ischemia, strategies.
 marked increases in blood pressure, or  Counsel clients, in collaboration with the healthcare team, to engage in moderate
 cardiac arrhythmias (atrial fibrillation). intensity dynamic exercise to be carried out for 30-60 minutes, 4 to 7 times a week.
 Discuss alcohol consumption with clients and recommend limiting alcohol use, as
appropriate to a maximum of:
 -Two standard drinks per day or 14 drinks per week for men; 5. Difficulty in swallowing or drooling.
- One standard drink per day or 9 drinks per week for women and lighter 6. Nausea or vomiting.
weight men 7. Personality changes.
8. Change in mood such as depression or apathy.
CVD, RIGHT THALAMIC INFARCTION 9. Drowsiness, lethargy or loss of consciousness.
10. Uncontrolled eye movements or eyelid drooping.
Cerebrovascular disease (CVD) or Cerebrovascular Infarction is a disease affecting the blood 11. Unusually severe headache
vessels which supply the brain and is caused by a stroke or brain disoder due to:
1. Narrowing or blocking of blood vessels caused by fatty accumulation and/or clot Medical Tests & Diagnosis Methods/Tools
formation leading to disruption of oxygenated blood supply to a portion of the brain. 1. Physical Examination
2. Bleeding either within the brain tissue (called cerebral hemorrhage) caused by 2. Cerebral Angiography or Vertebral Angiogram or Carotid Angiogram:
rupture of blood vessels in the brain. 3. Carotid Duplex or Carotid Ultrasound
Causes:  4. Computed Tomography (CT or CAT scan) 
 An ischemic stroke occurs when a blood vessel carrying blood to the brain is blocked 5. Doppler Ultrasound
by a clot and a hemorrhagic stroke occurs due to leakage of blood into the brain. 6. Magnetic Resonance Imaging (MRI)
 Brain cells may die if they do not receive blood and oxygen for a long a time.
Treatment
Risks:  I. Medications:
The controllable risks include: Blood platelet inhibitors such as:
1. Smoking  Aspirin,
2. Hypertension  Dipyridamole,
3. Carotid or other arterial disease: Narrowing of the carotid arteries due to plaque  Ticlopidine,
deposits reduces the supply of blood to the brain. A clot may cause complete  Clopidogrel
blockade of blood supply to brain.  Sulfinpyrazone
4. History of Transient Ischemic Attacks (TIA) II. Surgical Procedures: 
5. Diabetes
6. High cholesterol Carotid Endarterectomy:
7. Physical inactivity and obesity - In this procedure, an incision is made into the carotid artery and the plaque removed
8. Women are at risk of stroke during pregnancy or during the weeks immediately after with the help of a dissecting tool thus enabling normal blood flow. Then the artery is
delivery repaired with sutures or a graft
9. Alcohol and drug abuse III. Non-Surgical Procedures: 
Uncontrollable risk factors include:
1. Age
Carotid Angioplasty and Stenting:
2. Gender
- In this procedure, a balloon tipped catheter is inserted into the artery and the balloon
3. Heredity and Race
inflated to press against the plaque so as to flatten the plaque and reopen the artery.
4. Prior Stroke or Heart Attack
A tiny, slender metal mesh tube (stent) is fitted inside the carotid artery to improve
Signs & Symptoms
the blood flow in the arteries blocked by plaque. The stent helps in preventing the
1. Paralysis or weakness of an arm, leg and one side of the face.
artery from
2. Numbness or tingling with decreased sensation.
3. Changes in vision or loss of vision.
4. Inability to speak or slurred speech
Prevention Methods:
1. Quitting Smoking ANATOMY AND PHYSIOLOGY
2. Regular physical exercise
3. Eating heart healthy diet with low fat content CARDIOVASCULAR SYSTEM
4. Maintaining healthy weight or avoiding obesity Anatomy of the Heart:
5. Controlling blood pressure - Mediastinum
6. Controlling hypertension = between 2 lungs; size of the fist
7. Avoiding anger or chronic stress = positioned so the apex is directed towards the left hip while the base is pointing to
8. Lowering blood cholesterol the right shoulder
NURSING CONSIDERATIONS: *apex – 5th intercostal space
Acute Phase: *base – 2nd intercostal space
1. Maintain patent airway = double layered serous membrane
2. Maintain a BP of 150/100 mmHg to maintain cerebral perfusion
3. Suction as prescribed. Never suction nasally and for no longer than 10 seconds to prevent increasing - pericardium
ICP Inner – visceral pericardium – attached to the heart’s surface
4. Monitor ICP. Client is at most risk in the first 72 hours ff CVA. Outer – parietal epicardium
5. Position the client on the side. HOB elevated to 15 to 30 degrees as prescribed. Parietal – dense connective tissue & connects the heart with the surrounding
6. Monitor LOC structures.
7. Maintain fluid and electrolyte imbalance *the double layer serous membrane if a serous fluid for lubrication (so no friction
8. Prepare medications as prescribed e.g., mannitol, thrombolytics when pumping heart action)

Postacute Phase: Three Layers:

1. Continue implementation from acute phase. 1. Endocardium – thin layer if connective tissue line by endothelium (simple squamous)
2. Provide skin, mouth and eye care 2. Myocardium – thickest layer made of cardiac muscle and dense connective tissue (cardiac
3. Perform passive ROM exercises to prevent contractures skeleton)
4. Place antiembolism stockings on client to support
5. Measure thighs and calves for an increase in size, assess for positive Homan’s sign 3. Epicardium – thin layer of CT lined by mesothelium
6. Monitor gag reflex and ability to swallow
7. Slowly advance diet to foods that are easy to chew and swallow Chambers of the Heart
8. Provide soft and semisoft foods and fluids rather than liquids Right – Pulmonary Circulation
9. Position client sitting with the head and neck positioned slightly forward and flexed when eating Vena Cava → RA → Tricuspid Valve → RV→ Pulmonary Artery → Lungs → Pulmonary Veins →
LA
Chronic Phase: Left – Systemic Circulation
1. Approach client from the unaffected side Pulmonary veins → LA → Mitral (Bicuspid) Valve →LV → aorta → numerous branches
2. Place client’s personal objects within reach and within visual field →Body
3. Instruct the client with visual problems to turn the head from side to side
4. Increase mobility as tolerated Valves:
5. Encourage fluids and high fiber diet 2 Atrioventricular Valves:
6. Provide gait training Bicuspid /Mitral Valve = 2 flaps; left AV valve
Tricuspid Valve = right AV valve; 3 flaps
 Chordae Tendineae – tiny white chords that anchor 3 edges of cusps to the walls of 1. Middle – Late Diastole
the ventricles. - the heart us completely relaxed; intraventricular pressure is low.
Semilunar Valves - 3 cusps - blood is coming from the vena cava flows to the heart
- aortic and pulmonary valves - semilunar valves are closed
- no chordae tendineae - AV valves are open
Cardiac Circulation - end of this phase: atria contracts & force blood to go to the ventricles.
- supplied by the coronary arteries 2. Ventricular Systole
- coronary artery arise from the aorta (ascending part of the aorta) → atrioventricular - Ventricles now contract; pressure inside is ↑; IV pressure rise, semilunar valves are
groove intracardia braches blood coming from the heart → drained by cardiac veins → empty open , AV valves are closed; blood is rapidly injected to aorta & pulmonary artery.
into coronary sinus (post part of the heart) → RA. 3. Early Diastole
Conduction: - when the ventricles start to relax; semi lunar valves close; ventricular pressure
- Cardiac muscle in contrast with other muscles are different. If contracts drops; blood flows from aorta to ventricles.
independently, it can be controlled by:
Heart Sounds
1. Lub - longer, low pitched.
- closing of the AV valves
2. Dup / Dubb - shorter / high pitched
- closure of semi lunar valves

Microscopic Anatomy:
Blood Vessels: 3 layers:
1). Tunica Intima (Interna)
- composed of thin layer of CT covered by endothelium (simple squamous)
2). Tunica Media
- thick layers made up of alternating smooth muscles & elastic fibers.
3). Tunica Adventitia (Tunica Externa)
- made up of CT
- = to support & protect the BV from injury
1. Autonomic Nervous System - ↑ or ↓ heart rate
↑ - sympathetic (tachycardia) Capillaries:
↓ - parasympathetic (bradycardia) - thin walled minute vessels composed only of endothelium & its basement membrane.
2. Intrinsic Conduction System (ICS) / Nodal system
- specialized cardiac muscle cell Blood Pressure – pressure exerted by blood against the walls of the blood vessel
Main function: ensure cardiac muscles depolarization occurs only in one direction (atria to - force that keeps blood circulating continuously between heart beats.
ventricle) and to regulate the contraction rate of the heart. - highest in large arteries & continue to drop as arteries become smaller.

Cardiac Cycle of the Heart

- comprises the count of 1 complete heart beat during which both atria & ventricles NERVOUS SYSTEM
contracts and relaxes. 2 main divisions
1. Central nervous system: brain and spinal cord
Events in the Cycle: 2. Peripheral nervous system: cranial and spinal nerves
 a. Sensory or afferent division a. astrocytes- supply nutrients and help maintain electrical potential; form part of the BBB,
b. Motor or efferent division repair damaged neural tissue
b. ependymal cells- line the 4 ventricles and choroid plexus; help produce CSF
c. microglial- phagocytic cells; remove cellular debris
d. oligodendroglia- support and electrically insulate CNS axons forming the myelin sheaths

A.Central Nervous System

Brain- approximately 2% of body weight
3 major areas: Cerebrum, Brain stem, Cerebellum
*Cerebrum
 2 hemispheres: right and left which are incompletely separated by great longitudinal
fissure and joined at the lower portion by the corpus callosum
 4 lobes
-frontal lobe: personality, judgement, concentration, abstract thought, information
storage, movement, social behaviour, language expression
-parietal: sensory lobe, orientation to space and awareness of body shape
-temporal: hearing, language and comprehension, storage and recall of memories
-occipital: visual interpretation
Brain stem- relays messages between the Cerebrum, Diencephalon and spinal cord
Functional classification Cerebellum- has both excitatory and inhibitory actions and functions for smooth muscle
1. Somatic or voluntary movement
2. Autonomic or involuntary
Structures protecting the Brain
a. Sympathetic
*skull: frontal, temporal, parietal, and occipital
b. Parasympathetic *meninges: fibrous connective tissue; protect, support, and nourishes brain and spinal cord
LAYERS:
Cells of the nervous system o Dura matter: outermost layer; gray; covers the brain and spinal cord
*neuron is the basic functional unit o Arachnoid layer: thin (resembles a spider web; white; contains the choroid plexus
a. nerve cell body- ganglia or nuclei are nerve cell body in clusters
which produce and arachnoid villi that absorbs CSF (surrounds and cushions the CNS)
*center: cluster of cell bodies with the same function
CSF: 500ml; 125 to 150 ml is reabsorbed
b. dendrite: branch-type structure with synapses; receive messages
*subarachnoid space
c. axon: long projection; carry impulses away from the cell body
o Pia mater: hugs the brain closely and extends into every fold of the brain’s surface
Neurotransmitters: communicate messages from one neuron to another or another target
tissue Cerebrospinal fluid- clear and colorless fluid with similar characteristics with plasma; no RBC
and low WBC
These processes may belong to different types of neurons.  500 ml is produced everyday; only 150ml stays in the ventricular system at one time
 Afferent neuron: carries sensory information from the periphery to the CNS  CSF circulation
 Efferent neuron: carries motor commands form the CNS to the periphery of the body 1. Choroid plexus in the 2nd ventricle
Schwann cells- form the myelin sheaths around nerve fibers that forms in the PNS 2. Foramen of Monro (intraventricular foramen)
*neuroglial cells- nerve cell that protect, support, and nourish neurons 3. 3rd ventricle
 4. Aqueduct of Sylvius (cerebral aqueduct) Peripheral/ spinal nerves: 31 pairs= 8 cervical, 12 thoracic, 5 lumbar, 5 sacral and 1 coccygeal
5. 4th ventricle C. Somatic/ Involuntary- governed primarily by the cerebral hemisphere of the brain
6. 3 opening D. Autonomic Nervous System
a. 2 foramina of Luschka  Regulates the activites of internal organs such as the heart, lungs, blood vessels,
b. Foramen of Magendie digestive organs and glands
7. Subarachnoid space  Maintenance and restoration of internal homeostasis
8. Superior sagittal sinus DIVISIONS:
9. Arachnoid villi 1. Sympathetic NS: thoraco-lumbar outflow; predominantly excitatory; origin are
Blood-Brain-Barrier- mechanism that controls the passage of substances from the blood into located in the gray matter of the spinal cord from T1 through L2 or L3
the cerebrospinal fluid and thus into the brain and spinal cord  “fight and flight” response; norepinephrine
 Regulates body temperature, blood flow, blood pressure
Spinal cord: primary pathway for nerve impulses travelling between peripheral areas of the  Catabolic in nature
body and the brain 2. Parasympathetic NS: cranio-sacral outflow; mostly visceral functions;
acetylcholine
 Focused on the conservation of energy, replenishing and storage

 45cm (18 inches) long about the thickness of a finger

 Ends in the cauda equine
Structure protecting the Spinal Cord
 Vertebral column- surrounds and protect the spinal cord
B. Peripheral nervous System
Cranial nerves: 12 pairs; numbered in the oder in which they rise from the brain
 3 entirely sensory: CN I, II, VIII
 5 are motor: CN III, IV, VI, XI, XII
 4 are mixed: CN V, VII, IX, X
CLIENT IN CONTEXT PRESENT STATE INTERVENTIONS OUTCOME
B.P. 69 y/o, female, widow from Compostela, PHYSICAL EXAMINATION
Cebu was admitted for the first time at CVGH on E.R. Blotter
February 17, 2013 for slurring of speech and In: 12:25pm
decreased sensorium, under the services of Dr. Out: 1:41pm
Donaldo, Department of Internal Medicine with v/s: BP= 130/90 mmHg, PR= 64 bpm, RR=
a case no. of 12330/132940 at PPW-4 th floor 22cpm, T= 36.9C/axilla
room 400B.
DAY 1 February 22, 2013 3pm
History of Present Illness General Appearance: Examined lying on
bed, afebrile,coherent, conscious with the
3H PTA, patient was noted to have sudden following v/s: BP=140/90 mmHg, PR=65bpm,
slurring of speech not associated with other RR=19cpm, T=36.3C/axilla with IVF 6 PNSS 1L
neurologic deficits, vomiting, loss of @20cc/hr infusing well @L arm
consciousness, fever. Condition tolerated.
SKIN:
1H PTA, patient’s family had difficultywaking up Evenly colored brown without unusual
the patient from sleep, thus was brought to discoloration, skin is intact, smooth without
Eversley Sanitarium and was referred to CVGH lesions, easily pinched and immediately
for further management. On admission patient returns back to its original position (good
was drowsy at GCS 11 and noted to have skin turgor), skin rebounds and does not
dysrthria. No other neurologic deficits noted. remain indented when pressure is release,
Patient’s sensorium eventually noted improved with IVF 6 PNSS 1L @20cc/hr infusing well
and is already awake most of the time. Dysartria @L arm
was also improved. BP however is still
uncontrolled. SCALP & HAIR:
Black to grayish hair (natural), scalp is clean
Past Health History and dry, hair is smooth, without lesions or
lice infestation
 Patient is known hypertensive for 5 years and is
poorly compliant to Metoprolol 100mg OD. Not NAILS:
known diabetic and non-asthmatic. No known Clean, transparent, and well-trimmed nails
food and drug allergies. She has had no previous with light pink nail bed; has 160-degree
hospitalizations. angle between the nail base and the skin,
hard and immobile, smooth and firm, nail
Gordon’s Functional Health Pattern plate firmly attached to nail bed, CRT<2sec
(2 secs)
1.) Health Perception and Health Management
Pattern HEAD & FACE:
Symmetric, round, erect & in midline; hard
Patient’s own description of health is the state of and smooth without lesions or lumps. Head
physical, mental and emotional wellness is upright; no abnormal facial movements
verbalized by “pagkahimsug sa atong lawas”. Her noted, no swelling, tenderness, or
immediate health concern are hypertension and crepitation with movement.
slurred speech. She claimed that her current
condition makes her feel weak because she is not EYES & VISION
able to do the things she used to. She rated her Eyeballs are symmetrically aligned in sockets
health 7, 10 being the highest and 1 is the without protruding or sinking.Eyebrows are
lowest. She stated that her condition has black, same with hair color, symmetric and
continually improved. Her perception of general evenly distributed. Eyelids: Lashes evenly
state of health at present and its difference from spaced and curled outward. Bulbar
the usual state is that she feels weak and sickly as conjunctivae and sclera clear, moist, smooth
of now because she can’t do things like selling with tiny vessels visible; sclera are white.
crops in the market. Eating the right and healthy Pale palpebral conjunctivae, moist, and free
foods such as vegetables and avoiding ingestion of swelling, lesions, and abnormal
of salty and fatty foods support health discharges. Cornea &lens: transparent, moist
management activities. Patient had a family and without opacities; lens are clear. Iris is
incidence of lung cancer on maternal side. No round; uniform in color. (+) PERRLA.Corneal
family history of hypertension. light reflex: reflections of light noted at same
location on both eyes. Cardinal gaze: both
Environmental History eyes move in the same direction in a
coordinated manner in all six directions
Patient retired as a vendor of crops in a market.
Currently living in Compostela. Patient’s house is EARS AND HEARING:
already more than her age because it was built Ears are symmetric. External ear smooth,
by the time she was born. Their house is mixed, without lesions, lumps, or nodules; color
made up of woods and cement, 1 door leading consistent with facial color; with small
outside, 4 windows and 2 bedrooms, with a amount of odorless cerumen on the external
kitchen, living room, a toilet and a dining room ear, non-tender auricle and mastoid process;
that are all distinct and separate with each other. able to nod if being questioned if she was
 The type of toilet used is a flush-type and they able to hear the word “ballpen ” at 2ft
have a sewer drainage. Their source of electricity distance
is from VECO. For the drinking water, 3
containers of water are delivered to their home. NOSE:
They usually consume it every week and stated Midline, septum is straight and nares are
that it is enough for them. Their garbage is patent. No tendeness and discharges.
collected everyday by a garbage truck. They clean
their house in a daily basis. MOUTH and THROAT:
Lips are pale, moist without lesions, tongue
2.) Nutritional Metabolic Pattern at the midline without lesions, ulcers or
nodules, buccal mucosa is pale without
Patient’s weight 3 months ago is unrecalled. SO claimed lesions.
that she losses weight. She eats what is given to her in the
hospital. She has no food and fluid preference. When HEART and PERIPHERAL VASCULATURE:
stressed she eats or sleep. Her daughter shops and cooks No murmurs noted, no thrills or unusual
food. They store vegetables and fishes in the refrigerator pulsations noted, PR= 65bpm, Arms and legs
and other ingredients in a cabinet. bilaterally symmetric; no edema noted.
Both upper and lower extremity exhibited a
24 hour Diet recall capillary refill time of 2 seconds.

24 hr. U ABDOMEN:
recall s Umbilicus at midline, without bulging,
u lesions, masses, symmetrical, skin at
a abdomen is free from cicatrix, inflammation
l or rashes.
d
i GENITALIA: NOT ASSESSED
e
t ANUS: NOT ASSESSED
B Utan, rice Ric
r e, BACK AND EXTREMITIES:
e dri Upper and lower extremities symmetric in
a ed size, shape and movement, extremities are
k fis bilaterally warm to touch, CRT= 2 secs, full
f h ROM
a
s Muscle strength:
t Right upper extremity: 5/5
L Rice, Ric Left upper extremity: 5/5
u soup, e, Right lower extremity: 5/5
n fish, an Left lower extremity: 5/5
 c vegetable d
h s po Scales for grading muscle strength:
rk 5 – Active motion against resistance
D Rice, Ric 4 – Active motion against some resistance
i utan, e, 3 – Active motion against gravity
n chicken me 2 – Passive ROM
n at 1 – Slight flicker of contraction
e 0 – No muscular contraction
r
S Bread, Br GCS: 15
n milk ea Eye Verba Motor Response
a d, Ope l
c so ning Respo
k ftd nse
s rin 4- 5- 6-obeys
ks Spon orient commands
tane ed 5-localizes pain
3.) Elimination Pattern ous 4- 4-flexion
3-to confu withdrawal
BLADDER ELIMINATION voic sed 3-decorticate
Patient usually voids 4x a day with a light yellow- e 3- 2-decrebrate
colored urine and has a distinct odor amounting 2-to Inapp 1-no response
to 120 mL/episode. It is her typical pattern. Her pain ropria
approximate fluid intake is 8 glasses per day. She 1-no te
drinks coffee with 2 cups/day one in the morning resp words
and one during nighttime. she does not know onse 2-
and practice Kegel’s exercise. incom
prehe
BOWEL ELIMINATION nsible
Patient defecates once a day, usually in the sound
morning with a semi-solid brown stool. She s
sometimes postpone defecation. There is no 1-no
recent changes in her bowel patterns whether at respo
home or hospitalized. nse

4.) Activity – Exercise Pattern NEUROLOGIC ASSESSMENT:

A. MENTAL STAUS
Patient usually wakes up at 5am. She eats Client is awake, appears neat; clothes
together with her daughter and grandchildren. appropriate for weather, maintains good eye
They eat their lunch at 12nn. Spend time contact. Client is oriented to day and night
and when asked by the student nurse, “Mam
together with her grandchildren after meal. She unsa naman ta orasa ron?”, px replied “wala
has retired but occasionally sells fish around their ko kahibalo unsa na dyud orasa pero hapon
town to support her family. na ron”.

5.) Cognitive – Perceptual Pattern B.MOTOR/CEREBELLAR FUNCTION:

(+) Finger to nose tes, (+) finger to thumb
Patient can read and write but not too well since test (+) rapid alternating movement,
she’s only an elementary graduate. She speaks
Cebuano. She understands and perceives that C.SENSORY
her illness can affect lifestyle just like what she is Intact sensation to pain and light touch,
currently experiencing. She can recall her correctly differentiates between dull and
birthday (June 25, 1943) and the cause of her sharp sensation, correctly identified two
admission which was she had slurred speech and points on forearm, can smell orange and
decreased delirium. She has been hypertensive coffee with closed eyes
for 5 years and maintained Metropol 100 mg OD. (+) Stereognosis – correctly identified object
which is a hairpin and a coin
6.) Sleep – Rest Pattern (+) Graphesthesia – correctly identified
number written which is number 8
Before hospitalization, patient sleeps for 10 (+) Kinesthesia – patient correctly identified
hours and takes a nap for about an hour every direction of movements
afternoon. She usually sleeps at 7pm and wakes
up at 5am. This is her typical pattern. She claimed
to have a good and sound sleep but is easily Cranial nerve testing:
awakened whenever she feels the urge to void Olfactory: Client correctly identified scent of
only happens every nighttime. She easily falls coffee
asleep after being awakened to urinate. During Optic: Client able to see read student nurse’
hospitalization, patient’s pattern changed. She nameplate at 2-3 feet distance
does not have a definite time of retiring and Oculomotor, trochlear, abducens: full
arising because she is always awakened by visits extraocular movements; pupils are equally
from the nurses, interns and doctors. She uses 1 round and responsive to light and
blanket and 2 pillows, she sleeps in a supine or accommodation
side-lying position and there’s nothing that Trigeminal: Corneal reflex present; identifies
prevents her from sleeping in this positions. light, shape, dull touch to forehead, cheek,
and chin; clenches teeth.
7. Self Perception and Self Concept Pattern Facial: client correctly identifies taste of
orange, able to smile, wrinkle forehead, and
She feels she has a good sense of self worthiness show teeth.
though she perceives herself getting older. Her Vestibulocochlear: whispered words heard
illness affect her body image because she feels within 3 feet bilaterally
weak and sickly at the moment. Having a family Glossopharyngeal and vagus: uvula and
and raising her children is her major palate rise symmetrically when client says
accomplishment in her entire life. “ah”; gag reflex present; swallows without
difficulty
ROSENBERG’S SELF- S A DA SD Spinal accessory: client turns head in both
ESTEEM SCALE directions; equal shoulder shrug against
1. On the whole, I resistance
am satisfied with Hypoglossal: protrudes tongue in midline
myself
2. At times I think I DAY 2 September 23, 2012 02:00am
am no good at all General Appearance: Examined sitting on
3. I feel that I have bed afebrile, conscious, coherent with the
a number of good following v/s: BP=130/90mmHg, PR=70bpm,
qualities RR=20cpm, T=36.5C/axilla
4. I am able to do
things as most other EYES:
people do pale palpebral conjuctiva
5. I feel I don’t have
much to be proud MOUTH and THROAT:
of Lips are pale
6. I certainly feel
useless at times Muscle strength:
7. I feel that I am a Right upper extremity: 5/5
person of worth at Left upper extremity: 5/5
least an equal plane Right lower extremity: 5/5
with others Left lower extremity: 5/5
8. I wish I could
have more respect Scales for grading muscle strength:
for myself 5 – Active motion against resistance
4 – Active motion against some resistance
9. All in all I am
3 – Active motion against gravity
inclined to feel that
2 – Passive ROM
I am a failure
1 – Slight flicker of contraction
10. I take a positive
0 – No muscular contraction
attitude towards
myself
LABORATORIES:

8. Role – Relationship Pattern Complete Blood Count

Purpose: Used to evaluate infection or
Patient describes herself a s a good mother and potential for infection and identify various
grandmother. With her role both as a mother types of leukemia. (Lippincott Manual of
and grandmother in the family, she has to think Nursing Practice 8th Edition, pp. 935)
of the possible outcomes and consequences
before acting or declining. Her current health
status has not affected her relationship with her
family and others. Whenever she has problems
she turns to her daughter. She does not have any N.V. Feb
problems with communication, parenting or in 17,201
relatives. 3
W 4.10-10.9 k/uL 8.26
9. Sexuality Reproductive Pattern BC

Patient had menarche at 18 y/o with regular NE 2.50- 6.23

menstrual periods with associated U 7.5
dysmenorrheal. G11P11 all home deliveries
LY 1.00- 1.57
NSVD, no antecedent complications. Menopause
M 4.00
at 50 y/o, no abnormal vaginal bleeding
M 0.100- ..357
thereafter.
O 1.20
N
O
10. Coping-Stress Tolerance Pattern
EO 0.00- .047
S 0.500
She copes with stress by talking to others,
praying to God and going to sleep. She claimed
that it has been useful because her problems get
lessened. She relies on her daughter and other BA 0.00- .048
children to help her solve her problems. SO 0.100

11. Value – Belief Pattern

RB 4.50- 4.86
Patient is a Filipino and a Roman Catholic. Her C 5.90
religious activities include celebrating religious M/uL
holidays such as during Lenten season and
praying the rosary. She claimed that she has a HG 13.5- 15.3
good relationship with God because she prays B 17.50
and goes to church on Sundays. g/dL
HC 41.0- 44.7
T 53.0%
FAMILY GENOGRAM
M 80.0- 92.0
CV 100
 M 26.0- 31.5
CH 34.0 pg

M 31.0- 34.2
CH 36.0
C g/dL
RD 11.6 – 15.1
W 18.0
PL 140- 23.0
T 440
k/uL
M 0.00- 7.13
PV 9.99 fL

Implications:
Results are within normal range

February 17, 2013

X-ray:
Purpose: X-rays are especially useful in the
ECOMAP detection of pathology of the skeletal
system,, but are also useful for detecting
some disease processes in soft tissue. Some
notable examples are the very common
chest x-ray which can be used to identify
lung diseases such as pneumonia, lung
cancer pulmonary edema, and the
abdominal X-ray which can detect intestinal
obstruction, visceral perforations, and
ascites. X-rays may also be used to detect
pathology such as gallstoines and
kidneystones.

The lung fields are clear. Cardiac silhouette is

not enlarged.

Conclusion: normal heart and lungs.

February 17, 2013

CT-scan: brain-plain
Purpose: Purpose: A cranial computed tomography
(CT) scan uses many x-rays to create pictures of the
head, including the skull, brain, eye sockets, and
sinuses.

Conclusion: Chronic infarction Right

thalamus

Implications:
This maybe caused by fatty accumulation
and/or clot formation leading to disruption
of oxygenated blood supply to a portion of
the brain.

February 17, 2013

A glycosylated hemoglobin test (HbA1c) is a blood test
that measures the amount of glycosylated hemoglobin
in the blood. Hemoglobin is a protein found in the
blood. Glycosylated hemoglobin means that glucose
(sugar) has attached to the hemoglobin protein. The
higher your blood sugar is, the more that glucose gets
attached to your hemoglobin. This is unique to the
other blood glucose exams because it will measure the
past 4 months’ average blood glucose giving the
physician an idea about the patient’s compliance with
the medications or the body’s reaction to the regimen.

Glycosylated Hgb: 5.9% (n= 4.5-6.3%)

Implication: result is within normal range

February 17, 2013

Purpose: Blood clotting tests are used to
diagnose and assess bleeding problems and
to monitor people who take warfarin or
other anticoagulant medicines.

Clotting time: 2 mins 30 sec (n= 2-6 mins)

Implication: result is within normal range
 SERUM ELECTROLYTES
Purpose: Potassium testing is frequently
ordered, along with other electrolytes, as
part of a routine physical. It is used to detect
concentrations that are too high
(hyperkalemia) or too low (hypokalemia).
Blood sodium testing is used to detect
hyponatremia or hypernatremia associated
with dehydration, edema,
relating to the bones, heart, nerves, kidneys,
and teeth.

9/20/12
K+ (4.0- 3.9
5.6mmol/L)
Na (136-142 140
mmol/L)

Implications:
Decrease in potassium may be indicated due
to low intake of potassium rich foods such as
cantaloupe, raisins, oranges, watermelon,
dates, banana and spinach (CROWDS).

BLOOD CHEMISTRY
Purpose: These serum studies are collection
of commonly ordered tests (albumin,
bicarbonate, bilirubin, blood urea nitrogen,
calcium, carbon dioxide, chloride,
cholesterol, creatinine, electrolytes, globulin,
glucose, LDH, Magnesium, osmolality, Ph,
uric acid, etc) that can be done one at a
time. These tests vary widely among
laboratories, and the battery of tests may
include many different configurations.
Creatinine analysis of serum creatinine levels
provides a more sensitive measure of renal
damage.
 Feb 17, 2013
Crea (0.6-1.5 0.7
mg/dL)
LIVER FUNCTION TEST
ALT/SGPT (0-39 u? 19
L)
LIPID PANEL
Glucose (75-115) 148
Total cholesterol 206
(111-200)
TCG (0-200) 67
HDL cholesterol 55
(35-72) INTERVENTION DESIRED OUTCOME
1.Monitored BP throughout the Within 8 hours of SN – px
LDL (118-187) 138
day under same conditions interaction, the px will be able to:
VLDL (0-40) 13
R. Allows more accurate  Demonstrate improved tissue
comparison by controlling perfusion as manifested by normal
Implications:
external influences. vital signs
Increase in glucose may be indicated due to
2. Provided calm, restful  Good skin turgor
excessive ingestion of glucose and increase
environment  Normal intracranial pressure
in total cholesterol may be indicated due to
R. promotes relaxation  Presence of peripheral pulses
ingestion of fatty and foods.
3. Assessed skin for coolness,  CRT<2 seconds
pallor, cyanosis, diaphoresis.
R. Changed reflect diminished ACTUAL OUTCOME
Sept 21, 2012 @3:14
circulation and hypoxia After 8 hours of nursing intervention,
Urinalysis
4.Assessed CRT the px was able to:
Purpose: Urinalysis is a physical, chemical
R. to assess circulation  Manifest CRT<2 secs.
and microscopic analysis of the urine, and is
5. assessed and monitored  Pale lips
one of the routine tests. It is useful for
lower extremities for skin  Strong peripheral pluses
diagnosing renal disease or urinary tract
texture, edema and ulcerations  Dry skin
infection and for detecting metabolic disease
especially on pressure points.  Strong peripheral pulses
not related to kidney. The color, appearance,
R. Reduced peripheral
and odor of the urine are examined and the
circulation often leads to
Ph, protein, glucose, ketones and bilirubin
dermal changes and delayed
are tested with reagent strips. Its purposes
healing
include detecting normal versus abnormal
6. elevated the extremities with
urine components, to detect glycosuria and
one pillow
to aid in the diagnosis of renal disorder. 
R. To promote venous return DESIRED OUTCOME
Within 8 hours of student nurse – px
MACROSCOPIC Normal Findings
interaction, the px will be able to:
Color Light, dark Light yellow
INTERVENTION  Understand the importance of eating
 yellow 1.Took patients weight. nutritious food especially foods low
Clarity Clear Cloudy R. to determine the extent of in salt necessary for recovery
CHEMICAL TESTS malnutrition.  Will be able to maintain desired
pH 5-8 6 2. Encouraged to increase weight
Sp grav 1.001-1.035 1.010 intake of oral fluids especially
Protein <10 -- water once recovered. ACTUAL OUTCOME
Glucose Negative Negative R to keep the body dehydrated. after 8 hours of student nurse – px
Ketone Negative Negative 3. Encouraged SO to continue interaction, the patient and so was
Urobilinogen Negative Normal low salt low cholesterol diet able to:
and increase intake of fruit and  Cite examples foods rich in vitamin c
Blood Negative Negative
vegetables. such as calamansi, apples and
Bilirubin Negative Negative
R. Maintain balance of nutrient oranges.
MICROSCOPIC
consumption
RBC 0-3/hpf 2
4. Encouraged to eat foods rich
WBC 0-5/ hpf 5
in vitamin c such as orange.
Bacteria None Few R. To help boost immune
Epithelial cells Few -- system
5. Encouraged SO to feed
patient a well balanced diet of
Implications:
carbohydrates, protein and
Cloudy urine:
fiber.
Cloudy urine may indicate an impending urinary tract
R. Ensures that px receives all
infection
important food groups needed DESIRED OUTCOME
Date Identified: February 22,2013
for energy. Within the course of nursing interventions, the
Ineffective tissue Perfusion related to
patient will report improved sense of energy,
mechanical reduction of venous and arterial
perform ADLs and participate in desired
blood flow secondary to CVD right thalamus
activities at level of tolerance.
infarction
ACTUAL OUTCOME
SB: Decreased movement of blood from the
Independent Interventions After 8 hours of SN – SO interaction,
interstitium into the capillaries, arteries and
1. Determined the ability to the SO was able to:
venous blood flow. The mechanism
participate in activities/level of  Patient was able to have adequate
increased capillary permeability. Diminished
mobility. rest periods
tissue perfusion which is chronic in nature
R: Fatigue can limit the  Patient’s sense of energy improved
resulting to tissue or organ damage or death.
person’s ability o participate in
self-care and to perform her
responsibilities.
2. Assessed presence/degree of
sleep disturbances.
R: Changes in the person’s
sleep pattern may be a
 contributing factor in the
development of fatigue.
3. Arranged things within the
reach of the patient.
R: To provide an environment
conducive to relief of fatigue
and to prevent physical
exhaustion.
Date Identified: February 22,2013 4. Taught the patient how to
Imbalanced Nutrition less than body perform deep breathing
requirements related to decreased use of exercises.
nutrients associated with impaired ingestion R: To provide a way of
as manifested by observable weight loss as minimizing fatigue through
claimed by SO. relaxation. DESIRED OUTCOME
5. Reduced environmental Within the course of nursing interventions, the
SB: Adequate nutrition is necessary to meet stimuli. patient will be able to identify factors that
the body’s demands. Nutritional status can R: To promote relaxation and impair sleep and report improvement of sleep-
be affected by disease or injury states; to prevent any disturbances. rest pattern.
physical factors; social factors or 6. Placed care with consistent
psychological factors. rest periods between activities.
(http://nursingcareplan.imbalanced_05.html R: To conserve energy ACTUAL OUTCOME
) After 8 hours of SN – SO interaction,
the SO was able to:
 Patient was able to rest and sleep.
Increased energy level noted.
 Patient was able to verbalize “mao ra
gihapon, wa ko’y tarong nga tulog”.
INTERVENTION Patient was noted to resort to daytime
1. Assesses the normal sleeping pattern, naps to regain energy.
rituals and environment of the patient at
home.
R: In order for activities and surroundings
to be modified based on client usual
pattern.
2. Encouraged to do deep breathing
exercises.
Date Identified: February 22,2013 R: Deep breathing promotes relaxation
Fatigue r/t decreased oxygen supply to the brain and and diverts attention.
other parts of the body secondary to impaired blood 3 Suggested abstaining from daytime
circulation in right thalamic infarction as manifested naps.
by observable lack of energy and verbalization of R: Daytime naps impair ability to sleep at
“gikapoy ko” night.
4. Supported continuation of usual
Scientific Basis: bedtime rituals such as taking half-baths
Fatigue is a very common complaint and it is before going to sleep.
important to remember that it is a symptom and not a R: to promote relaxation and readiness for
disease. Many illnesses can result in the complaint of sleep.
fatigue and they can be physical, psychological, or a 5. Encouraged not to drink a lot of fluids
combination of the two. before bedtime.
Source:http://www.medicinenet.com/fatigue/article.h R: to minimize going to the comfort room
tm in the middle of the night.
6. Recommended quiet activities such as
reading or imagery or listening of music.
R: to reduce stimulation to promote
relaxation and cover up noise if present. DESIRED OUTCOME
7. Minimized going in and out of room. Within 8 hours of SN – SO
R: Allows patient to attain periods of interaction, the SO will be able to:
restful sleep.  Report improved general well being,
8.Provided adequate rest periods. the family will be able to establish
R: To promote rest and to maximize good communicating skills, establish
energy. rapport with the SN
9. Encouraged patient to restrict caffeine
intake and other stimulating substances. ACTUAL OUTCOME
R: They disrupt sleep patterns After 8 hours of SN – SO interaction,
10. Encouraged to drink milk the SO was able to:
R: L-tryptophan in milk induces sleep  Establish rapport with the SN
 Express feelings regarding px’s
condition
Date Identified: January 22, 2013 INTERVENTION  Was a little bit anxious but were
Disturbed Sleeping Pattern r/t uncomfortable sleep 1.assesses current actions of more understanding
environment as manifested by daytime naps and SO’s caregiver
verbalization of “mag-sige man na siya ug mata-mata R.To find out what needs to be
kada gabii”. changed
2. noted presence of high risk
situations
Scientific Basis: R. may necessitate role
Sleep is a form of hibernation when the body shuts reversal, resulting in added
down in order to repair damage done through use, to stress or place excessive
conserve energy demands.
3.determined current
Source: knowledge of the situation
http://drmyhill.co.uk/wiki/Sleep_is_vital_for_good_he R.May interfere with caregivers
alth_-_especially_in_CFS response to condition
4. Established rapport
R. To establish a therapeutic
relationship conveying
empathy.
5.Encouraged family to
communicate well among each
other
R. To share information and
develop plan for involvement in
care activities.
7. Identified equipment needs
or adaptive needs
R. To enhance the
independence and safety of the
caregiver
8. Encouraged to express
feelings
R. to assess and monitor the
emotional health of the
caregiver.

Date Identified: February 22,2013

Caregiver Role Strain related to
unpredictability of illness course as
manifested by verbalization of SO “ wa jud
ko magdahum na ma ingon ani ni siya:maau
ra man ni siya sa balay”

APPENDIX B
DRUG STUDY
MEDICATION CLASSIFIC ACTION INDICATION CONTRAINDI ADVERSE NURSING
ATION CATION EFFECTS CONSIDERATIO
NS
Citicholine Neuroton  Primarily functions as an CVD Hypersensiti Increased  Assess for CNS
ics intermediate in the vity, parasympath function and level
biosynthesis of the Hypertonia etic effects, of consciousness
phospholipids of cell of the fleeting &  Assess for
membranes. It also serves parasympath discrete hypersensitivity to
as a pre-cursor for the etic, hypotensor the drug.
neurotransmitter Pregnancy effect  May be
acetylcholine and administered
Lactating without regard to
food.
 Must not be
administered in the
late afternoon or at
night because it
can cause difficulty
sleeping.
 Contact physician
immediately if
allergic reactions
such hives, rash,
itching or swelling
occur.
Atorvastatin Antihyper  Inhibits HMG-CoA, the To reduce Hypersensiti Headache,  Obtain baseline
lipidemic enzyme that catalyzes the total vity, active flatulence, laboratory results.
HMG-CoA first step in the cholesterol cholesterol liver disease diarrhea,  Ensure patient
reductase synthesis pathway, or nausea, receives this drug
inhibitor resulting in a decrease in unexplained vomiting, at the same time
serum cholesterol, serum persistent anorexia, each day.
LDLs, and increases serum elevations of xerostomia,  Institute
HDLs serum angioedema, appropriate dietary
transaminas myalgia, changes.
e, porphyria, rash/pruritus  Monitor
pregnancy, , alopecia, cholesterol levels
lactation. allergy, throughout course
infection, of therapy.
chest pain.   Advise not to drink
grapefruit juice
while taking this
medication.
Captopril ACE  Competitively inhibits the Hypertension Known Hypotension,  Obtain baseline
inhibitors conversion of angiotensin I , hypersensitiv tachycardia, potassium levels.
(ATI) to angiotensin II (ATII), ity to the chest pain,  Assess patient’s
thus resulting in reduced drug. palpitations, heart rate and BP
ATII levels and aldosterone Bilateral pruritus, before
secretion. It also increases renal artery hyperkalaemi administration of
plasma renin activity and stenosis, a. drug.
bradykinin levels. hereditary Proteinuria;
 APPENDIX D  Instructed the SO to let the patient comply with take home medications to be given
DISCHARGE PLAN by the physician
 Instructed SO to let the patient take medication at the right dosage, right time, right
Discharge order given by Dr. Donaldo on February 17, 2013 at 4:00 pm route and right frequency
 Informed patient’s SO about the indication, contraindications and adverse effect of
MEDICATION the medication
 Instructed not to discontinue taking the medication when feeling well unless told by  Instructed SO to give medications at the right route, dose and time
the physician  Advised the patient to avoid strenuous activities.
 Instructed to take full course of therapy
OBSERVABLE SIGNS & SYMPTOMS
ENVIRONMENT  Advised patient to report immediately to the doctor for unusualities noted.
 Encouraged SO to maintain a clean, therapeutic environment at home
 Encouraged to maintain a safe home free from any hazards such as sharp objects, DIET
chemicals and matches  Advised to follow the right vitamin C and multivitamin supplements to be taken
 Instructed significant others to maintain a clean, well ventilated, comfortable and  Encouraged oral fluids at least 8 glasses per day
injury free environment conducive for recovery of patient  Encouraged patient to eat rich in fiber foods such as oatmeal.
 Instructed patient to stay away from people who have an infection such as colds or  Advised to increase fiber intake such as oatmeal
flu.-Instructed patient to stay from congested area  Advised patient to lessen or avoid fatty foods.
 Encouraged to have well ventilated environment.  Lessen or avoid sodium rich foods such as processed food
 Encouraged SO to keep environment conducive for rest and sleep.  Advised patient to lessen or avoid alcohol intake.
 Advised to eat vegetables
TREATMENT  Advised to watch body weight
 Instructed patient’s SO to have follow-up check-ups with physician
 Encouraged patient’s SO to fully participate in continuing treatment at home SAFETY/SPIRITUALITY
 Instructed S.O. to keep patient out from pollution/exposed areas-Instructed to take  Encouraged SO to continue praying to God and to attend mass every Sundays and
adequate rest and sleep, complete compliance of medications prescribed and proper other days
nutrition  Encouraged to keep and uphold pre-existing family values such as close family ties,
 Advised to modify lifestyle respect and love
 Advised client to consult immediately to physician in case her condition worsens.  Advised SO to provide support and attention to patient from her condition
 Advised to drink the medications prescribed by the doctor.  Advised to pray before and after meals.
 Encouraged oral fluids  Advised SO to keep faith with God
 Encouraged SO to follow health teachings given by the doctor and student nurses in  Advised patient and SO to continue patient’s relationship with God
order to avoid complications in the future.  Encouraged pray times for both patient and SO

HEALTH TEACHINGS Patient discharged ambulatory with improved condition

 Encouraged SO to give a good sleeping time and adequate nutrition
 Reminded SO to always assess patient needs
 Advised to perform exercises