A CASE STUDY OF

CEREBROVASCULAR DISEASE,
INFARCT;
HYPERTENSION S/P CVD

In Partial Fulfillment
Of the Requirements in Subject
NCM 102 RLE

Submitted to:
Prof. Emmanuel Taruc
Prof. Georgine Manantan
Prof. Marietta De Mesa
Prof. Michelle Flores
BSN Level III Clinical
Instructors

Submitted by:
Ma. Hyacinth Mae Adarme
Julie Mae Dela Rosa
John Michael S. Dominguez
Junalyn Vinzon

TABLE OF CONTENTS
I.INTRODUCTION
II.

GORDONS FUNCTIONAL PATTERN

III.

PHYSICAL ASSESSMENT

IV.

ANATOMY AND PHYSIOLOGY

V.

PATHOPHYSIOLOGY

VI. LABORATORY STUDIES/ DIAGNOSTIC PROCEDURE

VII. DRUG STUDY
VIII.

NURSING CARE PLAN

GRAND CASE Cerebro

PRESENTATIONVascular
Disease

Presented by:
Dominguez, John Michael S.
Vinzon, Junalyn
Dela Rosa, Julie Mae
Adarme, Hyacinth Mae

CVD, Infarct

Introduction

Introduction
Cerebrovascular disease is a group of brain
dysfunctions related to disease of the blood
vessels supplying the brain. Hypertension is
the most important cause; it damages the
blood vessel lining, endothelium, exposing the
underlying collagen where platelets aggregate
to initiate a repairing process which is not
always complete and perfect. Sustained
hypertension permanently changes the
architecture of the blood vessels making them
narrow, stiff, deformed, uneven and more
vulnerable to fluctuations in blood pressure.

Introduction

A stroke is caused by the

interruption of the blood
supply to the brain, usually
because a blood vessel bursts
or is blocked by a clot. This
cuts off the supply of oxygen
and nutrients, causing damage
to the brain tissue.

Introduction

The most common symptom of a

stroke is sudden weakness or
numbness of the face, arm or leg,
most often on one side of the body.
Other symptoms include: confusion,
difficulty speaking or understanding
speech; difficulty seeing with one or
both eyes; difficulty walking, dizziness,
loss of balance or coordination; severe
headache with no known cause;
fainting or unconsciousness.

Introduction
The effects of a stroke depend on which part of
the brain is injured and how severely it is affected.
A very severe stroke can cause sudden death.
The 1990 Global Burden of Disease (GBD) study
provided the first global estimate on the burden of
135 diseases, and cerebrovascular diseases
ranked as the second leading cause of death
after ischemic heart disease.
During the past decade the quantity of especially
routine mortality data has increased, and is now
covering approximately one-third of the worlds
population. The increase in data availability
provides the possibility for updating the estimated
global burden of stroke.

Introduction
Data on causes of death from the 1990s have shown
that cerebrovascular diseases remain a leading cause of
death.
In 2001 it was estimated that cerebrovascular diseases
(stroke) accounted for 5.5 million deaths world wide,
equivalent to 9.6 % of all deaths Two-thirds of these
deaths occurred in people living in developing countries
and 40% of the subjects were aged less than 70 years.
Additionally, cerebrovascular disease is the leading
cause of disability in adults and each year millions of
stroke survivors has to adapt to a life with restrictions in
activities of daily living as a consequence of
cerebrovascular disease. Many surviving stroke patients
will often depend on other peoples continuous support
to survive.

CVD, Infarct

Patients
Information

Patient
Information

A. Demographic Data:
Name: : Alfredo Sagun Velasco
Gender : Male
Age
: 63 yr old
Birth Date : April 08, 1952
Birth Place
: Tarlac

Patient
Information

Nationality
: Filipino
Religion
: Catholic
Civil Status
: Married
Address
: 63 Sikap St. Plainview
Mandaluyong City
Date of Admission : Sept 22, 2015
Date of Interview : :Aug 10, 2015

CVD, Infarct

Chief Complaint

Chief
Complaint
Reason for Seeking Care/Chief
Complaint
(+)Slurred speech

CVD, Infarct

Past Health
History

Past Health
History

(+) HTN non compliant with Nefidifine

(-) DM
(-) ASTHMA
S/P CVD no residual (2010)

CVD, Infarct

History of
Present illness

History of Present
Illness
Few hours PTA (Morning)
(+) Slurred Speech
(+) Headache
(-) Dizziness

CVD, Infarct

Family History

Family
History

(+) Heart Diseases

(-) Diabetes

CVD, Infarct

Social History

Social
History

+ 20 pack years cigarette smoking

+ Alcohol beverage drinker

CVD, Infarct

Gordons
Functional
Pattern

Gordon
Function
Pattern

Before
Hospitalization

During
Hospitalization

Analysis

Patient perceives his self He perceives his self as

Health is state of complete
Health
as
unhealthy because he
physical, mental and social
Perception/ unhealthy. He believes that cant eat well and he cant well-being, and not merely the
Health
eating all kinds of food
vigorously move his left-side absence of diseases.
Management make an individual healthy. body. He is oriented to date, (KOZIER Vol. 1, pg 295)
He takes over-the-counter time and place. He shows Most people define health as
medication for simple
interest to cooperate in his being free from the signs and
cough and colds.
recovery. He accepts and symptoms of disease and pain
listens to health teaching. (KOZIER VOL1, pg172)
He takes only medication
prescribed by his physician.
He consults first before
taking any medications and
for any alternative
medication.

Gordon
Function
Pattern

Before
hospitalization

During
Hospitalization

Analysis

Nutritional/ Patient usually eats 2 cups He is on soft diet and on The bodys most basic nutrient
of rice per meal with beef, low sodium low fat diet. No is water. Nutrition is what the
Metabolic pork or chicken. He usually nausea and vomiting noted. person eats and how the body
drinks alcohol and smoke
20 packs for a year.
Patient drinks 20004000cc of fluid in a day,
including coffee and soft
drinks, most of the time.

No difficulty in swallowing.
Difficulty in eating. Pale
conjunctiva and hair loss
indicating insufficiency in
nutrition.

uses it.(Fundamentals of
Nursing 8th edition, Kozier and
Erbs, pg.1232)
The older adult requires the
same basic nutrition as the
younger adult. However, fewer
calories are needed by elders
because of the lower
metabolic rate and decrease
physical ability. (KOZIER
VOL.2, pg1243)
Diagnosis: Imbalanced
Nutrition: less than body
requirements r/t inability to
ingest because of biological
factor.

Gordon
Function
Pattern
Eliminatio
n

Before
hospitalization

During
Hospitalization

According to him, he
He urinates 4-5 times a day
urinates 5-6 times a day. approximately 2500cc. His
Her urine is light yellow in urine is clear. No
color, clear. No pain during discharges present and
urination. No discharges pain in urination. He has
noted. She defecates 3
negative defecation for 9
times a week. Light brown days.
in color and formed stool.
No pain during defecation
and no discharges noted.

Analysis
The average urine output of an
older adult is 1500ml or less.
Most people void 5-6 times a
day.
(Fundamentals of Nursing,
Kozier, pg1290)
Normal patterns of bowels
vary considerably. For some a
normal a normal pattern may
be every other day, others
twice a day. ( KOZIER VOL.2,
pg 1327- 1328).

Gordon
Function
Before
During
Pattern hospitalization Hospitalization
is sometime
Activity He
engaged in sports
such as basketball
/
with his friends.
Exercis
e

Analysis

He has limited activity Activity- exercise pattern refers to a

with assistance to avoid persons routine of exercise, activity,
any injury that may
tasks and habits including ADLs that
happen because of
requires energy expenditure quality
hemiparesis. He is
exercise. ( KOZIER VOL2, pg 1059)
sometime unable to
With aging comes gradual reduction in
practices turning her
the speed and power of skeletal or
body side to side every 2 voluntary muscle contractions and
hours for 30 minutes
sustained muscular efforts. Activities
because of body malaise can still be carried out, but at a slower
causes insufficient blood pace, and with greater expenditure of
circulation.
energy. Often balance is impaired with
age, and is related to loss of muscle
strength. ( KOZIER VOL.1, pg 411)
Diagnosis: Risk for pressure ulcer r/t
Impaired bed mobility d/t
neuromascular impairment

Gordon
Function
Before
During
Pattern hospitalization Hospitalization

Sleep/
Rest

Analysis

He is having a normal
He sleeps at 8pm and Sleep is a basic human need.
sleeping pattern usually 6- wakes up at 4 or 5am. He Sleep plays a vital role in good
8hrs in a day.
usually has 1-2 hours of health and well-being. Getting
nap in the afternoon. He enough quality sleep at the
uses 1 pillow on her head. right times can help protect
There is an interruption of mental health, physical health,
sleep at night because of quality of life, and safety.
vital signs monitoring.
Most healthy adult need needs
7-9 hours of sleep at night.
(KOZIER VOL2, pg1169)

Gordon
Function
Before
During
Pattern hospitalization Hospitalization
Cognitive/ He had a problem in
hearing.
Perceptual

Analysis

Patient is oriented to time Perception or the ability to

and date. He shows ability interpret the environment
to perceive the environment depends on the acuteness of
and react appropriately but the senses. If the aging
has a unrecognizable
persons senses are impaired,
speech (slurred speech).
the ability to perceive the
environment and react
appropriately is diminished.
(KOZIER VOL.1, pg 418)

Gordon
Function
Before
During
Pattern hospitalization Hospitalization
He is a jolly person, easy
Selfto deal with and has many
perception vices.
/
selfconcept

He is now sensitive but still

cooperative. According to
him, as of now he became
shy because of his
condition.

Analysis
Coping is described as
dealing with problems and
situations. It is an innate or
acquired way of reproducing
to a change in environment.
( KOZIER VOL2, pg20)
Diagnosis:
Impaired Verbal
communication r/t recent
mild stroke

Gordon
Function
Before
During
Pattern hospitalization Hospitalization
Role/
Relationshi
p

He is married. He also well Patient has visitors whom

supported and loved by his are his wife and his
family and friends with
daughter whom continues
close relationship.
to help and assists him.

Analysis
A role is a set of expectations
of about how the person
occupying one position
behaves. Role performance
relates what a person in
particular does to the behavior
expected of that role.
(Fundamentals of Nursing 8 th
ed. By Kozier and Erbs,
pp1006)
The relationship of the family
ties is more strengthened.
There is a presence of role
ambiguity because
expectations are unclear and
unable to predict the outcome
of her hospitalization. And
whether she can assume
again her role as provider
upon discharge.

Gordon
Function
Before
During
Pattern hospitalization Hospitalization
Patient has no history of
Sexuality/
Reproductive Sexual Transmitted

Disease or any disease

affecting his genitals area.
No family planning method
used. He had been
circumcised at the age of
13 years old

No changes. He has 2
daughters and a son.

Analysis
Sexual health is an individual
and constantly changing
phenomenon falling within the
wide range of human sexual
thoughts, feelings, needs and
desires. (Fundamentals of
Nursing 8th ed. By Kozier and
Erbs, pp.1019)

Changes in sexual responses

have for decades been
considered normal
consequences of aging.
Desire may or may not change
with aging; levels of desire
may remain the same
throughout life. (Gerontological
Nursing 2nd ed. By Kristen L.
Mauk, p. 618)

Gordon
Function
Before
During
Pattern hospitalization Hospitalization
Coping
Stress/
Toleranc
e

Analysis

He is usually talking with He is able to accept

Coping is described as dealing
his friend whenever he has situation by cooperating
with problems and situations.
a problem or when he is with the medical advices
It is an innate or acquired way
stressed. He sleeps, drink and procedures. He wants of reproducing to a change in
alcohol or smoke when he to go home as soon as
environment. ( KOZIER VOL2,
is stressed.
possible. Sleep is his stress pg20)
reliever.

Gordon
Function
Before
During
Pattern hospitalization Hospitalization

Value/
Belief

Patient is a Roman
Catholic. He doesnt pray
at night. He rarely went to
church.

He cant attend mass

because he is admitted in
hospital but he prays
seldom.

Analysis
Prayer involves a sense of
love and connections, as well
as reaching out. It has many
health benefits and healing
property, it also offers a means
of someone to talk to.(KOZIER
VOL.2, 1004)

CVD, Infarct

Physical
Examination

Physical
Examination

General
Survey

General Survey
Date Assessed: September 28, 2015
Time: 8:00 a.m.

Vital Signs:
Temperature: 37.2C
Pulse Rate: 82 bpm
Respiratory Rate: 14 cpm
Blood Pressure: 110/70 mmHg
O2 Saturation: 98%

Physical
Examination

Physical
Assessment

Physical Assessment
BODY PART NORMAL FINDINGS
SKIN
Evenly colored
skin
tone, intact skin,
no reddened area,
no lesion,
no edema,
warm
temperature.
Skin pinches easily
and immediately
returns to its
original
position.

FINDINGS
Evenly colored
skin tone,
intact skin,
no reddened
area,
no lesion,
no edema,
warm
temperature.
Skin pinches
easily
and immediately
returns to its
original position.

ANALYSIS
Normal

Physical Assessment
BODY PART NORMAL FINDINGS

FINDINGS

ANALYSIS

SCALP AND Clean and dry

scalp. Natural hair
HAIR
color, Smooth and
firm hair, evenly
distributed, no
lice,
no dandruffs.

Hair is black with

minimal white
hair
strands.
Fewer
distribution
of hair on the
parietal part.
No dandruff
observed.

NORMAL

Physical Assessment
BODY PART NORMAL FINDINGS

FINDINGS

ANALYSIS

HEAD AND Normocephalic and

FACE
symmetrical.
No lesion visible.

Normocephalic,
no masses or
tenderness notes
upon palpation.
No lesions present.

NORMAL

Physical Assessment
BODY PART NORMAL FINDINGS
NECK

FINDINGS

No palpable masses Uniform in color.

and no tenderness. No mass.

ANALYSIS
NORMAL

Physical Assessment
BODY PART NORMAL FINDINGS
LYMPH
NODES

No tenderness,
no masses,
no enlargement

FINDINGS
No tenderness,
no masses,
no enlargement

ANALYSIS
NORMAL

Physical Assessment
BODY PART NORMAL FINDINGS
EYES

Placed evenly,
symmetrical,
non-protruding in
eyes,
pink and clear
conjunctiva,
white sclera,
pupils are reactive to
light.

FINDINGS
Parallel and evenly
placed.
Non-protruding

ANALYSIS
Pale
conjunctiva
supports
CVD

conjunctiva is pale.
white sclera
reactive to light.

indication.

Physical Assessment
BODY PART NORMAL FINDINGS
EARS

Color is the same

with face,
symmetrically
aligned auricle with
outer cantus of the
eye,
with minimal hearing
problem.

FINDINGS
Color is same in
face, symmetrical
and flexible.
With minimal
hearing problem.

ANALYSIS
Minimal
hearing
problem due
to
manifestation
of old age.

Physical Assessment
BODY PART NORMAL FINDINGS
MOUTH
Lips are smooth,
moist, pinkish, no l
lesion or swelling.
32 teeth and ivory
color.
Gums are pinkish,
moist, firm
and no masses or
lesion.
Midline tongue.
Present of gag reflex.

FINDINGS
24 teeth,

ANALYSIS
Asymmetrical

oral mucosa and

and
lips are pale in
uncontrollable
moist mouth
color,
because of
uncontrollable
recent mild
moist mouth and
stroke that
causes the
there were no oral numbness
feeling on his
ulcers or lesions.

left side face.

Midline tongue.
Pale color
Present gag reflex. supports CVD
indication,
Asymmetrical

Physical Assessment
BODY PART NORMAL FINDINGS
NOSE

FINDINGS

Symmetrical and
Symmetrical,
straight. No
some
discharges or flaring.
uncontrollable
discharges.

ANALYSIS
Some
uncontrollable
discharges
because of the
feeling of
numbness on the
left side of his
face.

Physical Assessment
BODY PART NORMAL FINDINGS
POSTERIOR Symmetrical chest
THORAX expansion.
AND
No retraction.
ANTERIOR
THORAX

FINDINGS

ANALYSIS

Symmetrical chest

NORMAL

expansion.
No retraction.

Physical Assessment
BODY PART NORMAL FINDINGS
HEART

Sound heart beat.

Lub-dub.
No murmur.

FINDINGS

ANALYSIS

Sound heart beat.

NORMAL

Lub-dub.
No murmur.

Physical Assessment
BODY PART NORMAL FINDINGS
ABDOMEN

No discoloration,
lesion, rashes,
evenly
rounded, NABS, no
masses, swellings,
seldom palpable
spleen.

FINDINGS
Non-tender upon
palpation, flabby,
soft, NABS.

ANALYSIS
NORMAL

Physical Assessment
BODY PART NORMAL FINDINGS
Equal in length,
UPPER
EXTREMITIES no lesion,

FINDINGS

Equal in length,
no lesion,
no deformities
no deformities on
on extremities
extremities and
and with complete
with complete
digits.
digits.
Uniform body
Uniform to body
temperature.
temperature.
No edema.
No edema.
Skin pinches easily
Skin pinches
and immediately
easily and
returns to its
immediately
original position.
returns to its
Normal Capillary refill original position.
Normal Capillary
test.
refill test.

ANALYSIS
NORMAL

Physical Assessment
BODY PART NORMAL FINDINGS
Equal in length,
LOWER
EXTREMITIES no lesion,

FINDINGS

Equal in length,
no lesion,
no deformities on
no deformities on
extremities and with extremities and
complete digits.
with
Uniform to body
complete digits.
temperature.
Uniform to body
No edema.
temperature.
Skin pinches easily No edema.
and immediately
Skin pinches
returns to its
easily and
original position.
immediately
Normal Capillary refill returns to its
original position.
test.
Normal Capillary
refill test.

ANALYSIS
Normal

Physical
Examination

Neurological
Examination

Neurological Examination

Glasgow
Coma
Scale
Eye
Openin
g

Scor
e

(4)Spontaneously
(3)To Speech
(2)To Pain
(1)None

Neurological Examination

Glasgow
Coma
Scale
Verbal
Respons
e

Scor
e

(5)Oriented
(4)Confused
(3)Inappropriate
(2)Incomprehensibl
e
(1)None

Neurological Examination

Glasgow
Coma
Scale
Motor
Respons
e

Scor
e

(6)Obeys commands
(5)Localizes to pain
(4)Withdraws from pain
(3)Flexion to pain
(2)Extension to pain
(1)None

Neurological Examination

Glasgow
Coma
Scale

Total
Score

Best Response:
15
Comatose Client:
8 or Less
Totally
Unresponsive:
3

Score

10

Neurological Examination

Cerebrum: (+) Facial Asymmetry

Cerebellum: Weakened Left extremities

4/5

5/5
c

5/5

4/5

Motor

100
%
100
%

50
c%

++

50
%

++

Sensory

++
c

++

Reflexes

CVD, Infarct

Anatomy
&
Physiology

Anatomy &
Physiology
The Brain
Three cavities, called the primary brain vesicles, form
during the early embryonic development of the brain.
These are the forebrain (prosencephalon), the midbrain
(mesencephalon), and the hindbrain (rhombencephalon).
The telencephalon generates the cerebrum (which
contains the cerebral cortex, white matter, and basal
ganglia).
The diencephalon generates the thalamus, hypothalamus,
and pineal gland.
The mesencephalon generates the midbrain portion of the
brain stem.
The metencephalon generates the pons portion of the
brain stem and the cerebellum.
The myelencephalon generates the medulla oblongata
portion of the brain stem

Anatomy &
Physiology

Cerebrum=

motor, sensory, integrative

function
Frontal= controls higher cortical
thinking, personality development,
motor activity, contains brocas are or
the motor speech center (expressive
aphasia)

Anatomy &
Physiology

Anatomy &
Physiology
The

cerebrum consists of two cerebral

hemispheres connected by a bundle of nerve
fibers, the corpus callosum. The largest and
most visible part of the brain, the cerebrum,
appears as folded ridges and grooves, called
convolutions. The following terms are used
to describe the convolutions:
A gyrus (plural, gyri) is an elevated ridge
among the convolutions.
A sulcus (plural, sulci) is a shallow groove
among the convolutions.
A fissure is a deep groove among the
convolutions.

Anatomy &
Physiology
Occipital:

vision
Parietal: pain, pressure heat and cold
Tempural: hearing, short term memory, contains
the general interpretative
Area Wernickes aphasia
Limbic system: sense of smell, libido or sexual
urge control, long term memory
Basal Ganglia: produces dopamine (control gross
voluntary movement)
Midbrain: sight and hearing particularly helps in
size and reaction of pupils and hearing acuity.

Anatomy &
Physiology

Diencephalon
Thalamus:

relay station for sensation

Hypothalamus: controls temp, blood pressure,
sleep and wakefulness, thirst, appetite, emotional
responses like fear, anxiety and excitement,
controls pituitary functions.

Anatomy &
Physiology

Brain

Stem
Pons: controls rate, rhythm and depth of
respiration
Medulla Oblongata: damage most life
threatening: controls respiration, heat rate and
swallowing

Anatomy &
Physiology
The

diencephalon connects the cerebrum to the brain

stem. It consists of the following major regions:

The thalamus is a relay station for sensory nerve impulses

traveling from the spinal cord to the cerebrum. Some nerve
impulses are sorted and grouped here before being
transmitted to the cerebrum. Certain sensations, such as
pain, pressure, and temperature, are evaluated here also.
The epithalamus contains the pineal gland. The pineal
gland secretes melatonin, a hormone that helps regulate
the biological clock (sleep-wake cycles).
The hypothalamus regulates numerous important body
activities. It controls the autonomic nervous system and
regulates emotion, behavior, hunger, thirst, body
temperature, and the biological clock. It also produces two
hormones (ADH and oxytocin) and various releasing
hormones that control hormone production in the anterior
pituitary gland.

Anatomy &
Physiology

Anatomy &
Physiology
The cerebellum consists of a central region, the vermis,
and two winglike lobes, the cerebellar hemispheres. Like
that of the cerebrum, the surface of the cerebellum is
convoluted, but the gyri, called folia, are parallel and give
a pleated appearance. The cerebellum evaluates and
coordinates motor movements by comparing actual
skeletal movements to the movement that was intended.
The limbic system is a network of neurons that extends
over a wide range of areas of the brain. The limbic system
imposes an emotional aspect to behaviors, experiences,
and memories. Emotions such as pleasure, fear, anger,
sorrow, and affection are imparted to events and
experiences. The limbic system accomplishes this by a
system of fiber tracts (white matter) and gray matter that
pervades the diencephalon and encircles the inside border
of the cerebrum. The following components are included:

Anatomy &
Physiology
The

hippocampus (located in the cerebral

hemisphere)
The denate gyrus (located in cerebral
hemisphere)
The amygdala (amygdaloid body) (an almondshaped body associated with the caudate nucleus
of the basal ganglia)
The mammillary bodies (in the hypothalamus)
The anterior thalamic nuclei (in the thalamus)
The fornix (a bundle of fiber tracts that links
components of the limbic system)

CVD, Infarct

Predisposing
Factors

Predisposing Factors
1. Thrombosis- attaches clot #1 cause of stroke
2. Emboli- detached/ wandering thrombosis
Pulmonary embolism
-. Sudden sharp chest pain
-. Unexplained dyspnea
-. Tachycardia
-. Palpitation
-. Diaphoresis
Cerebral embolism
-. Headache
-. Dizziness
-. Disorientation
-. Change in LOC that may lead to coma
3. Hemorrhage

CVD, Infarct

Risk
Factors

1.
2.
3.
4.
5.

-.
-.
-.

-.
-.
-.

HPN
DM
Atherosclerosis- MI
Valvular heart disease mitral/post cardiac surgery/ mitral valve
replacement mlt CVA
Lifestyle
Smoking
Sedentary lifestyle
Obesity (more than 20% ideal body weight)
Diet rich in saturated fats
Hyperlipidemia
Type A personality
Deadline driven person
Does several things at the same time
Feels guilty when not doing anything
Prolonged use of oral contraceptives
Macropil estrogen
Minipil progestine
Increases lipolysis breakdown of lipids- atherosclerosis- HPN- CVA

Clinical manifestation
1. Transient Ischemic Attack- initial
sign of CVA
Headache,
dizziness,
tinnitus,
visual and speech disturbances,
paresis to plegia, increase in ICP
possible,
cheyne

stroke
respirations
1. Stroke in evolution progression of
S/sx
2. Complete Stroke- resolution phase
characterized by still dizziness and
headache

Pathophysiology

MODIFIABLE FACTORS:
Smoking
Ingestion of fatty foods
Hypertension

Vasospasm

Increase
oxygen
demand

Embolus
that
dislodge

Decrease
oxygen
supply in
the blood

Inadequate
blood
perfusion

Motor,
sensory,
cranial
nerves
disrupted
Dizziness,
stiffening of
extremeties,
and non
projectile
vomiting

Cell
injury
and
death
Cerebrovascul
ar disease

Laboratory
Tests

Hematology
Report
Complete
o
o
o
o
o
o
o

Blood Count

Hemoglobin: 136 gm/L (M 140-180gm/L)

Hematocrit: .39 (M .40 -.54)
Erythrocyte Count: 4.23 (4-6x10raiseto12/L)
Leukocyte: 6.6 (5-10x10raiseto9/L)
Differential:
SEGMENTERS: .75 (0.45-0.65)
Lymphocytes: .25 (0.20-0.35)

Chemistry Report
Creatinine

90 (53-115umol/L)

Glucose
(FBS)

4.84 (3.9-6.4mmol/L)

Urea
Nitrogen

3.74 (2.6 9.2mmol/L)

Uric Acid

413 (M 214-488 umol/L)

Na (+)

141.8 (135-146mmol/L)

K (+)

3.29 (3.6-5.5 mmol/L)

SGOT

36.0 (<35 U/L)

SGPT

28.5 (<41U/L)

Cholesterol

4.57 (<5.2mmol/L)

HDL

0.92 (>1.0mmol/L)

LDL

3.01 (<4.0mmol/L)

CT Scan
Impression:
1.Lacunar infarcts, both internal capsules
and right thalamus.
2. Chronic small vessel ischemic changes
in periventricular regions.
3. Slight cerebro cerebellar atrophy
4. Atherosclerotic vessel disease
5. Suggest follow-up contrast study.

Chest PA
FINDINGS:
Faint Upper lobe and paracardiac opacity
Heart is enlarged
Aortic knob is prominent
The rest of the study is unremarkable
IMPRESSION:
Consider PTB rule out underlying pneumotitis
Atheromatous Aorta

Drug Study

Name of Drug Mechanism of Action Dosage

Generic name: Dcrease total

Indication
- Adjunct to

daily PO

diet to slow

Diarrhea, Constipation,
Vomiting, Flatulence.

cholesterol and

Calcium

tryglycerides in pt

atheroscleros

with primary

is

5-40mg

Rosuvastatin

hypercholesterolemia

Adverse effect

progression

GI: Nausea, Dyspepsia,

CV: Hypertension,
Angina Pectoris

in patients
with elevated

CNS: Headache,

cholesterol.

Dizziness, Insomnia,
Anxiety, Vertigo,
Neuralgia, Paresthesia,
Depression

Respi: Pneumonia,
Dyspnea, Rhinitis,
Sinusitis

Nursing Care Plan

 Patients

Name: Bed #6
Diagnosis: Cerebrovascular disease,
infarct; hypertension
Date of Birth: 12/17/1952
Date of Admission: 04/22/2015
Age:63 years old
Gender:
Male
Dr. Cabballar

ASSESSMENT

DIAGNOSIS

Imbalanced
Hindi niya maigalaw ng Nutrition: less
than body
maayos ang kanyang
bibig as verbalize by
requirements r/t
the significant others.
inability to ingest
because of
OBJECTIVE:
biological factor.
SUBJECTIVE:

Slurred speech
Difficulty of raising
his hand
Conscious and
coherent
Hair loss (Alopecia
areata)
Pale conjunctiva
Brittleness of hair

Vital Signs:

Temperature:
37.2C
Pulse Rate: 82 bpm
Respiratory Rate:
14 cpm
Blood Pressure:
110/70 mmHg
O2 Saturation: 98%

PLANNING

INTERVENTION

Short Term

Independent:

After 24 hours of
nursing
intervention the
patient would
manifest pink
conjunctiva.

Monitor patients
conjunctiva and hair.

Long Term
After 2-3 days of
nursing
intervention the
patient would
demonstrate
normal hair
texture and
lessened hair
loss.

Teach client proper

nutritional diet.

OUTCOME/Evaluation
After 24 hours of
nursing intervention the
patient manifests pink
conjunctiva.

Teach healthy
lifestyle in
accordance with the
vices like smoking
and alcoholism.

After 2-3 days of

nursing intervention the
Administer parenteral
patient demonstrates
nutrition as ordered
normal hair texture and
by the physician.
lessened hair loss.
Dependent:

Collaborative:

Refer to a nutritionist
in having a more
accurate proper diet.

Assessmen Diagnosis
t
Subjective:
nahihirapan siya
magsalita as
verbalized by the
significant others
and as observed.
OBJECTIVE:

Slurred speech
Difficulty of
raising his hand
Difficulty of

turning from one

side to another
Conscious and

coherent
Vital Signs:
Temperature:
37.2C
Pulse Rate: 82 bpm
Respiratory Rate:
14 cpm
Blood Pressure:
110/70 mmHg
O2 Saturation: 98%

Impaired Verbal
communication
r/t recent mild
stroke

Planning

Short Term
Within 4-6 hours
of nursing
intervention
patient should an
alternative form of
communication to
fulfill his basic
needs.
Long Term
Within 2 days of
nursing
intervention
patient should an
alternative form of
communication to
interact with
others to fulfill
other needs like
social, emotional
and spiritual
needs.

Nursing Evaluation
Interventi
on
Independent
Assess the
patients preferred
means for
communication
such as verbal,
written or
gestures.
Assess for inability
to communicate
verbally and
inability to
understand
language.
Monitor speech
improvement.
Collaborative
Refer to a
psychiatrist and/or
physical therapist if
needed because of
speech impairment.

Patient uses
an alternative
form of
communicatio
n to fulfill his
basic needs.
Patient uses an
alternative form of
communication to
fulfill his other
needs like social,
emotional and
spiritual needs.

ASSESSMENT

DIAGNOSIS

PLANNING

INTERVENTION

SUBJECTIVE:

Risk for pressure

ulcer r/t Impaired
bed mobility d/t
neuromascular
impairment

Short Term

Independent:

After 3-4 hours

of nursing
intervention the
patient would
demonstrate
comfort on the
back and sacral
area.

Nanghihina kalahati ng
katawan niya as
verbalized by the
significant others and as
observed.

OBJECTIVE:

Slurred speech
Difficulty of raising
his hand
Difficulty of turning
from one side to
another
Conscious and
coherent

Vital Signs:
Temperature: 37.2C
Pulse Rate: 82 bpm
Respiratory Rate: 14
cpm
Blood Pressure:
110/70 mmHg
O2 Saturation: 98%

Long Term
After 2 days of
nursing
intervention the
pt. will not
manifest
pressure ulcer.

Turn pt. q
2hrs
Perform
proper bed
making

Monitor vital
signs

Side rails up

OUTCOME/Evaluation

After 3-4 hours of

nursing intervention the
patient would
demonstrate comfort on
the back and sacral
area.
After 2 days of nursing
intervention the pt. did
not manifest signs of
pressure ulcer.