JMJ Marist Brothers

Notre Dame of Marbel University

College of Arts and Sciences – Nursing Department
Koronadal City, South Cotabato

Patient’s Name: Rose Mae Vera Chief Complain: Slurring of speech

Age: 53/Female Date & Time of Admission: April 29, 2021;
Case No.: 2918-0221 5:15 AM
Attending Physician: Dr. Suarez

CASE 7: Cerebrovascular Accident, Bleed Vs. Infarct

History of Present Condition:

At April 29, 2021, 5:00 AM, Mrs. Rose, a 53 year-old client, experienced a sudden
onset of slurring of speech, had facial drooping on her left hand side with weakness of her left
arm and leg. This happened when she was eating her breakfast. Her husband, Mr. Jack, had
a keen eye with these symptoms and immediately rushed her to the nearest emergency room.
They arrived 15 minutes after.

Past Medical History:

(+) Hypertension
(+) Hyperlipidemia

Home medications prior to admission:

Taking Atorvastatin 25 mg/tab OD at PM

Taking Amlodipine 10 mg/tab OD at AM; Losartan 50 mg/tab OD at PM

Social History:

Mrs. Rose is a 53 year-old employee of a janitorial and service agency assigned in a

local government office. During her off days, she also does the laundry of some boarders near
her home. She usually works 50-60 hours/week.

She has 2 adult children, both are married. 1 lives in Surallah, South Cotabato, the
other is a domestic helper overseas.

She is an ex-smoker, smoking 30 years x 5-10/day. She quit 5 years ago following her
diagnosis of hypertension and hyperlipidemia.

Emergency Department Assessment:

Mrs. Rose came to ER per stretcher complaining of slurring of speech and weakness
of left arm and leg. Vital signs were taken as follows: BP= 170/100mmHg, PR= 109 bpm, RR=
24cpm, temperature is 37.10C, SPO2= 97%. She was placed on an NPO status.

(+) Left Facial Droop

(+) Left Motor Weakness; Left arm 0/5; Left Leg 2/5
(+) Slurred speech
 JMJ Marist Brothers
Notre Dame of Marbel University
College of Arts and Sciences – Nursing Department
Koronadal City, South Cotabato

DOCTOR’S ORDER
Date Time Progress Notes Order C A R E D
4/29/2021 0515AM (+) Left facial droop Admit to ROC under the service of Dr. Suarez / /
(+) Left motor Secure consent for admission. /
weakness
(+) Slurred speech NPO / /
Start PNSS 1L x 20 gtts/min / / /
V/S Labs: / / /
BP=170/100mmHg CBC PC
PR=109 bpm; Creatinine, Lipid Profile, SGPT, SGOT, S. K+
RR=24cpm; XRAY Chest PA
Temp= 37.1 0C ECG
SPO2= 97% RBS now
CT Scan Plain and contrast
RBS=92mg/dl O2 at 2 LPM via nasal cannula / / /
Start Nicardipine drip at Nicardipine 10 mg + / / /
90 ml NSS x 10 mgtts/min via soluset
Hold maintenance meds for now. /
Meds: / / /
1. Mannitol 200 mL IV Bolus now then 100 mL
q4h
2. Paracetamol 1 ampule IV for fever / /
Hook patient to cardiac monitor with pulse / /
oximeter at room.
Refer for unusualities. / /
Dr. Ricafort

KIM NATHALIE F. ALISASIS, SN/ JAN

MAVERICK S. RABINO, RN 04/29/21 5:30am
4/29//2021 5 45 AM Thank you for this referral; Seen & examined: / /
t/c Cerebrovascular Accident Bleed Vs Infarct
Carry out orders of Dr. Ricafort / /
Okay with CT Scan Plain and contrast; refer if / /
with results
Insert foley catheter and attach to urobag / /
Increase VS and NVS monitoring to q2 / /
Maintain NPO; insert NGT and open to drain / /
Titrate nicard drip to maintain MAP 80-110 / /
Refer accordingly. / /
Continue Meds. / / /
Dr. Suarez

KIM NATHALIE F. ALISASIS, SN/ JAN

MAVERICK S. RABINO, RN 04/29/21 6:00am
Legend: C – Carried Out A – Administered R – Requested E – Endorsed D - Discontinued

Patient’s Name: Rose Mae Vera Age/Sex: 53/F Hospital No. 2912-1
Attending Physician: Dr. Suarez Room No.: 101
 JMJ Marist Brothers
Notre Dame of Marbel University
College of Arts and Sciences – Nursing Department
Koronadal City, South Cotabato

DOCTOR’S ORDER
Date Time Progress Notes Order C A R E D
4/29/2021 9 00 AM CT Scan: Dx: Acute Ischemic Stroke / /
Hyperdensity in the Ideally, patient is for rTPA IV stat during onset of CVA / /
m1 segment of the Repeat ECG now / / /
Right Middle Cerebral RBS now / /
Artery; generalized Discussed with family regarding possible ICU / /
mild cerebral edema admission if condition deteriorates.
ECG: Normal sinus
rhythm Dr. Suarez

KIM NATHALIE F. ALISASIS, SN/ JAN

MAVERICK S. RABINO, RN 04/29/21 9:10am
9 15 AM RBS: 80 mg/dl Maintain NGT Open to drain / /
(+) NGT output 50 cc RBS at 2pm / /
(-) Swallowing reflex Inform labs once available / /

Dr. Suarez
KIM NATHALIE F. ALISASIS, SN/ JAN
MAVERICK S. RABINO, RN 04/29/21 9:20am
4/29/2021 2 00 PM RBS: 75 mg/dl May start OTF 6AM tomorrow at 800 kcal divided into 6 / /
VS: BP: 140/90 equal feedings; inform if not tolerated; may give milk
with equal amount for tonight
RR: 19 cpm Meds:
PR: 87 bpm 1. Omeprazole 40 mg IVTT now then OD @ 6AM / / /
T: 37.0 2. Amlodipine 5 mg/tab OD @ 6AM / /
(-) NGT output 3. Kalium durule 1 tab; TID / /
S. K+: 2.0 4. Atorvastatin 25 mg/tab 1 tab OD @ HS / /
UO: 1000 mL 5. Citicoline 250 mg/amp; 1 amp now then q8H / / /
MAP: 106 For complete 24h CT Scan tomorrow / / /

GCS: 12 / /
Refer for unusualities.
Dr. Suarez

KIM NATHALIE F. ALISASIS, SN/ JAN

MAVERICK S. RABINO, RN 04/29/21 2:20am
Legend: C – Carried Out A – Administered R – Requested E – Endorsed D - Discontinued
Patient’s Name: Rose Mae Vera Age/Sex: 53/F Hospital No. 2912-1
Attending Physician: Dr. Suarez Room No.: 101
 JMJ Marist Brothers
Notre Dame of Marbel University
College of Arts and Sciences – Nursing Department
Koronadal City, South Cotabato

MEDICATION SHEET

Date MEDICINES Date 04/29/21 Date

Ordered Shift Time Initial Time Initial Time Initial Time Initial Discontinued

04/29/21 Mannitol 200 mL IV 6A-2P 10:00am KNFA

Bolus q4h 12:00pm
2P-10P
10P-6A
04/29/21 Omeprazole 40 mg 6A-2P
IVTT OD @ 6AM 2P-10P
10P-6A
04/29/21 Amlodipine 5 mg/tab 6A-2P
OD @ 6AM 2P-10P
10P-6A
04/29/21 Kalium durule 1 tab; 6A-2P
TID 2P-10P
10P-6A
04/29/21 Atorvastatin 25 6A-2P
mg/tab 1 tab OD @ HS 2P-10P
10P-6A
04/29/21 Citicoline 250 mg/amp; 6A-2P
1 amp q8H 2P-10P
10P-6A
PRN
Date MEDICINES Date Date
Ordered Shift Time Initial Time Initial Time Initial Time Initial Discontinued

04/29/21 Paracetamol 1 ampule 6A-2P

IV for fever 2P-10P
10P-6A
STAT ORDERS
Date MEDICINES Date 04/29/21 Date
Ordered Shift Time Initial Time Initial Time Initial Time Initial Discontinued

04/29/21 Mannitol 200 mL IV 6A-2P 5:30am

Bolus now
2P-10P
10P-6A
04/29/21 Omeprazole 40 mg 6A-2P 2:15pm KNFA
IVTT now
2P-10P
10P-6A
04/29/21 Citicoline 250 mg/amp; 6A-2P 2:20pm KNFA
1 amp now
2P-10P
10P-6A

MEDICATION NURSE
Shift Full Name & Initial Full Name & Initial Full Name & Initial
 JMJ Marist Brothers
Notre Dame of Marbel University
College of Arts and Sciences – Nursing Department
Koronadal City, South Cotabato

6A- KIM NATHALIE F.

2PM ALISASIS, SN/KNFA
2P-
10P
10P-
6A

Patient’s Name: Rose Mae Vera Age/Sex: 53/F Hospital No. 2912-1
Attending Physician: Dr. Suarez Room No.: 101
 JMJ Marist Brothers
Notre Dame of Marbel University
College of Arts and Sciences – Nursing Department
Koronadal City, South Cotabato

RBS MONITORING SHEET

Date Time RBS INSULIN GIVEN DOSE ROUTE GIVEN
BY:
04/29/21 5:15am 92mg/dL KNFA
04/29/21 9:15am 80mg/dL KNFA
04/29/21 2:00pm 75mg/dL KNFA

Shift Full Name & Initial Full Name & Initial Full Name & Initial Full Name & Initial
6A-2PM KIM
NATHALIE
F. ALISASIS, SN/KNFA
2P-10P
10P-6A
Patient’s Name: Rose Mae Vera Age/Sex: 53/F Hospital No. 2912-1
Attending Physician: Dr. Suarez Room No.: 101
 JMJ Marist Brothers
Notre Dame of Marbel University
College of Arts and Sciences – Nursing Department
Koronadal City, South Cotabato

PARENTERAL FLUID SHEET

I. INTRAVENOUS FLUIDS
Date Bottl Solutio Incorporati Rate Time Signatur Date/Time Signatur Remark
e n on Starte e Discontinu e s
No. d ed
04/29/2 #1 PNSS 20gtts/mi 5:20
1 1L n am

II. SIDE DRIPS

Date Bottl Solutio Incorporati Rate Time Signatu Date/Time Signatu Remar
e n on Starte re Discontinu re ks
No. d ed
04/29/2 #1 PNSS Nicardipin 10mgtts/m 5:30
1 90 ml e 10mg in via am
soluset

III. BLOOD TRANSFUSIONS

Date Bag Blood Serial Rate Time Signature Date/Time Signature Remarks
No. Type No. Started Discontinued

Rose Mae Vera 53/F 101 Dr. Suarez 2918-0221

Patient’s Name Age/Sex Room No. Attending Physician Patient No.
 JMJ Marist Brothers
Notre Dame of Marbel University
College of Arts and Sciences – Nursing Department
Koronadal City, South Cotabato

VITAL SIGNS MONITORING SHEET

Date Time BP CR RR Tem Initial Date T B CR RR Temp Initial
p i P
m
e
04/29/ 5:15a 170/100 109 24 37.1 KNFA
21 m mmHg bpm cpm °C
04/29/ 6:00a 150/90 104 23 36.9 KNFA
21 m mmHg bpm cpm °C
04/29/ 8:00a 140/80 100 21 37.0 KNFA
21 m mmHg bpm cpm °C
04/29/ 10:00a 130/ 90 95 19 36.8 KNFA
21 m mmHg bpm cpm °C
04/29/ 12:00p 140/80 90 20 36.9 KNFA
21 m mmHg bpm cpm °C
04/29/ 2:00p 140/90 87 19 37.0 KNFA
21 m mmHg bpm cpm °C

MONITORING STAFF
Full Name & Initial Full Name & Full Name & Full Name &
Initial Initial Initial
KIM NATHALIE F.
ALISASIS, SN/KNFA

Rose Mae Vera 53/F 101 Dr. Suarez 2918-0221

Patient’s Name Age/Sex Room No. Attending Physician Patient No
 JMJ Marist Brothers
Notre Dame of Marbel University
College of Arts and Sciences – Nursing Department
Koronadal City, South Cotabato

NURSES NOTES AND TREATMENT RECORD

DATE SHIFT FOCUS DOCUMENTATION SIGNATURE

TIME
04/29/21 6a-2p Received lying on bed c IVF #1 PNSS 1L x 20gtts/min @ 1000cc level,
6:00am hooked @ R metacarpal vein, intact, patent and infusing well.---------------
F- Impaired verbal communication D- (+) slurred speech, (+) L facial
drooping, (+) L motor weakness, GCS=12, (+) incomprehensible verbal
response, BP=170/100mmHg PR=109 bpm; RR=24cpm; Temp= 37.1 0C
SPO2= 97%.------------------------------------------------------------------------------
A- Placed in a comfortable position, Reduced environmental noise and
provided adequate lighting, Ascertained client’s attention before
communicating, Determined cultural factors that may hinder effective
communication such as use of touch and eye-contact, Established rapport
by initiating and maintaining eye contact, listening attentively, and
attending to nonverbal cues, Assessed hearing and visual senses,
Assessed ability to write, Asked simple questions in short sentences,
using appropriate words, Spoke slowly and clearly in a calm and unhurried
manner, Provided sufficient time to response and avoided frequent
corrections, Validated meaning of nonverbal cues and avoided making
assumptions, Provided alternative methods of communication (pad,
pencil, slate board, pictures, hand/eye signals, tablet/cellphone), Provided
a simple, straightforward and honest statements, Involved s/o in making a
plan of care and techniques for communication, Monitored VS and NVS
q2, Administered O2 @ 2 Lpm via nasal cannula, Administered mannitol
as ordered.--------------------------------------------------------------------------------
F- Impaired bed mobility D- (+) L motor weakness, Left arm 0/5; Left Leg
2/5, (+) impaired ability to reposition self in bed----------------------------------
A- Adjusted level of bed, Provided mattress or padding, Assessed muscle
strength, Performed skin examination for both extremities and observed
for signs of compromised circulation and pressure ulcers, Assisted in
ADLs, Provided passive ROM on the affected site, Changed position q2,
Encouraged s/o to provide frequent skin care, massage, and passive
exercises on the affected site, Raised side rails.---------------------------------
2:00pm R-Established a method of communication through hand signals, pictures,
pad, and pen, Maintained skin integrity, s/o demonstrated passive
exercises, Endorsed to NOD c IVF #1 PNSS 1L x 30 gtts/min @ 460cc
level, hooked @ R metacarpal vein, intact, patent and infusing well.--------
-------------------------------------------KIM NATHALIE F. ALISASIS, SN/KNFA
**Post operative notes at the floor

Patient’s Name: Rose Mae Vera Age/Sex: 53/F Hospital No. 2912-1
Attending Physician: Dr. Suarez Room No.: 101