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Formal grand case presentation
1. GRAND CASE PRESENTATION
Stroke In The Young
PTB IV
A Clinical Case Study
Presented to
The GCP Committee and
Faculty of Bachelor of
Science in Nursing
City university of Pasay (Formerly Pamantasan Ng Lungsod Ng Pasay
Pasay City
In partial fulfillment of the requirements in
NCM 106 Related Nursing Experience
By:
BSN IV-1
GROUP 1
School Year 2013-2014
2. TABLE OF CONTENTS
Introduction 2
Objectives 4
Patient’s Profile 5
History of Present Illness 5
Past Medical History 17
Family Health History 18
Drug History 20
Lifestyle History 22
Growth & Development 25
Physical Assessment 30
Vital Signs 38
Anatomy and Physiology 47
Signs & Symptomatology 58
Pathophysiology 60
Medical Management 64
Laboratories & Diagnostic Examinations 67
Drug Study 75
Intravenous Therapy 93
Diet Therapy 94
Surgical Management 96
Nursing Management 97
Algorithm of Care 102
5. Globally, stroke is the second leading cause of death above the age of 60 years, and the fifth leading cause of death in people aged 15 to 59 years
old.
Stroke is less common in people under 40 years, although it does happen. In young people the most common causes are high blood pressure or
sickle cell disease. In many developed countries the incidence of stroke is declining even though the actual number of strokes is increasing
because of the ageing population.
In the developing world, however, the incidence of stroke is increasing. In China, 1.3 million people have a stroke each year and 75% live with
varying degrees of disability as a result of stroke. The predictions for the next two decades suggest a tripling in stroke mortality in Latin America,
the Middle East, and sub-Saharan Africa.(2013 , World Heart Federation)
A study found that the average age of people who experienced stroke fell from 71 years in1993 and 1994 to 69 years in 2005. In addition, the
study found that strokes among people under 55 made up a greater percentage of all strokes over time, growing from about 13percent in 1993-94
to 19 percent in 2005. The stroke rate in young people increased from 83 strokes per 100,000 people in 1993-94 to 128 per 100,000 in 2005 in
African-Americans, and from 26 strokes per 100,000 people in 1993-94 to 48 per 100,000 in 2005 in Caucasians. (National Stroke Association)
IN THE Philippines, stroke is one of the top five causes of death. Although it is very common, most Filipinos who experience an impending stroke
don't recognize the symptoms of in denial that he has a "brain attack."
According to the latest WHO data published in April 2011 Stroke Deaths in Philippines reached 40, 245 or 9.55% of total deaths. The age adjusted
Death Rate is 82.77 per 100,000 of population ranks Philippines # 106 in the world.
"A stroke event must be dealt with just like a heart attack," declares Dr. Alejandro F. Diaz, an associate professor of neurology at the University of
Santo Tomas. "The phrase brain attack was coined to mean that stroke is always an emergency. A 'wait and see' attitude has no room in the
management of this serious disease. Even when stroke symptoms are perceived as mild, the condition should still get immediate medical
attention."(Henrylito D. Tacio Monday, August 1, 2011)
1
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6. GeneralObjective:
The main objective of the group is to be able to present the case study of our chosen patient that would provide a clinical guide to a safe and
quality nursing care, in a day to day changes in health care.
Specific Objectives:
1. To enhance the knowledge with regards to the patient’s general health and disease condition, its pathophysiology, possible
complications, treatment plan and medical regimen.
2. To assimilate skills through application of several nursing interventions and medical management.
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7. 3. To improve the student’s attitude by conveying open-mindedness and utilizing therapeutic communication all throughout the
activity.
4. To formulate a plan of care for patients with CVA.
5. To formulate comprehensive nursing diagnosis for a client with CVA.
6. To evaluate the plan of care for a patient with CVA
PATIENT’S HEALTH INFORMATION
Patient’s Personal Profile
Patient R.B. is 71 year old, female, widow, born on April 07, 1942 at Samar. He is a Born Again Christian and currently
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8. residing at Pasay City with his son. She was an OFW for 10 years in Japan and a Domestic Helper in Hong Kong for four years.
Patient G.C was admitted on August 12, 2013 at 4:00pm, Medical Ward, Female Medical Ward, bed number 1, at Pasay
City General Hospital under Admitting Physician Dr. Daphne Goldameir C. Alicday with the admitting diagnosis of CVA Infarct.
Chief Complaint: Left Sided Body Weakness
Present Health History
1 hour prior to Admission
(August 12, 2013) At 3:00pm, Patient R.B. was working, washing clothes, when she suddenly felt dizzy. And then, she felt
numbness on the left side of her body. Her son noted there was facial assymetry and slurring of speech. Patient uttered that the
feeling was like having anesthesia. She was immediately rushed at Emergency Room of Pasay City General Hospital at
4:00pm.
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9. Past Medical History
Patient C.A. had her first stroke on 2005. She was admitted at Pasay City General Hospital. During that time she experienced left sided
weakness. She was admitted for 2 weeks. After discharge, she had her physical therapy at the same hospital for a month. She had full recovery
after about 1 year. She was able to continue her activities of daily living and performing household chores.
Personal and Social History
Patient R.B. is a 71 year old woman, widow. She three children who had their own family. She used to work at Japan for ten
years as an Overseas Filipino Worker. She also work as a Domestic Helper in Hong Kong for four years. After her recovery from her
first stroke in 2005, she just stayed at home and started her sari-sari store business.
Patient R.B is currently residing at P. Dandan St., Pasay City. They are living in a studio type, cemented room with 1 door
and 1 window. Their water source is NAWASA which they use for cooking, bathing and washing clothes. Their source of electricity is
from Meralco.
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10. Monitoring Sheet for:
TEMPERATURE
DATE 8:00 AM 12:00 NN 4:00 PM 8:00 PM 12:00 MN 4:00 AM
August 12,
2013
35.9 36.4 36.6 36.7 36.3 36.0
August 13,
2013
36.8 36.5 37.5 36.8 363 37.2
August 14,
2013
36.3 36.1 36.5 36.1 36.6 36.7
August 15,
2013
36.3 37.5 36.5 36.0 37.0 37.5
August 16,
2013
37.3 37.0 36.5 36.8 37.3 36.0
August 17,
2013
37.3 37.3 36.8 37.0 36.3 36.5
August 18,
2013
35.2 36.0 36.3 36.0 37.0 36.8
August 19,
2013
37.3 37.0 36.8 36.5 36.7 37.0
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11. August 20,
2013
36.5 36.0 36.3 36.0 36.3 37.0
August 21,
2013
36.7 36.0 36.2 36.5 36.5 36.1
August 22,
2013
35.9 36.4 36.6 36.7 36.3 36.0
August 23,
2013
36.4 36.5 * 38.7 * 39.1
LEGEND (*) = not monitored
TABLE presentation for Temperature monitoring every 4 hours
ANALYSIS:
The normal temperature of an individual ranges from 36.5 to 37.5 ºC. In the case of our patient, his temperature
ranges from 35.2 ºC to 39.2 ºC.
The patient experienced increase in temperature because of atherosclerosis (hardening of the arteries) causing
damaged to endothelial cells.
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13. Monitoring Sheet for:
CARDIAC RATE
DATE 8:00 AM 12:00 NN 4:00 PM 8:00 PM 12:00 MN 4:00 AM
August 12,
2013
35.9 36.4 36.6 36.7 36.3 36.0
August 13,
2013
36.8 36.5 37.5 36.8 363 37.2
August 14,
2013
36.3 36.1 36.5 36.1 36.6 36.7
August 15,
2013
36.3 37.5 36.5 36.0 37.0 37.5
August 16,
2013
37.3 37.0 36.5 36.8 37.3 36.0
August 17,
2013
37.3 37.3 36.8 37.0 36.3 36.5
August 18,
2013
35.2 36.0 36.3 36.0 37.0 36.8
August 19,
2013
37.3 37.0 36.8 36.5 36.7 37.0
August 20,
2013
36.5 36.0 36.3 36.0 36.3 37.0
August 21,
2013
36.7 36.0 36.2 36.5 36.5 36.1
August 22,
2013
35.9 36.4 36.6 36.7 36.3 36.0
August 23,
2013
36.4 36.5 * 38.7 * 39.1
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14. LEGEND (*) = not monitored
TABLE presentation for Cardiac rate monitoring every 4 hours
ANALYSIS:
The normal pulse rate ranges from 60 to 100 beats per minute. In the case of our patient, his pulse rate ranges from 51 to
140 beats per minute so the pulse rate is higher than the normal range.
Elevation in cardiac rate may occur to the patient as a compensatory mechanism in order to supply blood to the parts of
the body and other extremities.
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15. Monitoring Sheet for:
RESPIRATORY RATE
DATE 8:00 AM 12:00 NN 4:00 PM 8:00 PM 12:00 MN 4:00 AM
August 12,
2013
35.9 36.4 36.6 36.7 36.3 36.0
August 13, 36.8 36.5 37.5 36.8 363 37.2
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16. 2013
August 14,
2013
36.3 36.1 36.5 36.1 36.6 36.7
August 15,
2013
36.3 37.5 36.5 36.0 37.0 37.5
August 16,
2013
37.3 37.0 36.5 36.8 37.3 36.0
August 17,
2013
37.3 37.3 36.8 37.0 36.3 36.5
August 18,
2013
35.2 36.0 36.3 36.0 37.0 36.8
August 19,
2013
37.3 37.0 36.8 36.5 36.7 37.0
August 20,
2013
36.5 36.0 36.3 36.0 36.3 37.0
August 21,
2013
36.7 36.0 36.2 36.5 36.5 36.1
August 22,
2013
35.9 36.4 36.6 36.7 36.3 36.0
August 23,
2013
36.4 36.5 * 38.7 * 39.1
LEGEND (*) = not monitored
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17. TABLE presentation for Respiratory rate monitoring every 4 hours
ANALYSIS:
The respiratory rate of our patient ranges from 13 to 32 cycles per minute. It is within normal range.
It is particular to patient with re-stroke probably infarct to have rapid respiration to compensate for the needs of
oxygen in the circulation. The body increases oxygen demand supply in the tissue. In order to meet the demand, the respiratory
system will compensate by increasing the respiratory effort which leads to an increase respiratory rate.
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18. Monitoring Sheet for:
BLOOD PRESSURE
BLOOD PRESSURE
LEGEND (*) = not monitored
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DATE August 12,
2013
August 13,
2013
August 14,
2013
August 15,
2013
August 16,
2013
August 17,
2013
August 18,
2013
TIME 8am 12 nn 8am 12 nn 8am 12 nn 8am 12 nn 8am 12 nn 8am 12 nn 8am 12 nn
ACTUAL 160/1
10
180/1
30
* *
140/1
00
140/1
00
140/1
00
130/9
0
210/1
10
130/1
00
* *
180/9
0
180/9
0
MAP 270 310 * * 240 290 240 220 320 230 * * 270 270
EXPECTED 140/80 value = 70-110
19. TABLE presentation for Blood Pressure monitoring every 4 hours
ANALYSIS:
The blood pressure of our patient during his confinement ranges from 90/70 to 210/110. Hypertension has been noted in
our patient
Hypertension is a major risk factor for stroke and nephropathy, in adequately treated hypertension augments of which
nephropathy develops.
Increased in blood pressure may indicate interruption in blood flow. Increase in Mean Arterial Pressure indicates increased
cerebral perfusion while decreased Mean Arterial Pressure indicates bleeding.
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20. INTAKE AND OUTPUT
DATE AND
TIME OF
SHIFT INTAKE OUTPUT
ORA
L
PARENTER
AL
TOTA
L
URINE DRAINAGE BM TOTAL
08-12-2013
6 am to 2
pm
300 350 350 (-)
2pm to
10pm
300 250 400 1x
10pm to
6am
(-) 300 200 (-)
TOTAL
08-13-13
6 am to 2
pm
600 300 600 (-)
2pm to
10pm
300 100 500 1x
10pm to (-) 850 1,500 (-)
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21. 6am
TOTAL
8-14-13
6 am to 2
pm
600 470 550 1x
2pm to
10pm
300 300 100 (-)
10pm to
6am
(-) 350 1000 (-)
TOTAL
08-15-13
6 am to 2
pm
600 500 1000 (-)
2pm to
10pm
280 200 400 (-)
10pm to
6am
TOTAL
08-16-2013
6 am to 2
pm
600 550 400 (-)
2pm to
10pm
(-) (-) (-) (-)
10pm to
6am
(-) (-) (-) (-)
TOTAL
08-17-2013
6 am to 2 600 300 800 (-)
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22. pm
2pm to
10pm
300 (-) 1100 1X
10pm to
6am
(-) 200 800 (-)
TOTAL
08-18-2013
6 am to 2
pm
(-) (-) (-) (-)
2pm to
10pm
300 500 500 (-)
10pm to
6am
(-) 400 1 DC 1DC
TOTAL
08-19-2013
6 am to 2
pm
OFI 100 300 1X
2pm to
10pm
350 100 200 (-)
10pm to
6am
100 200 300 (-)
TOTAL
08-20-2013
6 am to 2
pm
350 450 2DC (-)
2pm to
10pm
280 800 1DC (-)
10pm to
6am
(-) 150 2DC (-)
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23. TOTAL
08-21-2013
6 am to 2
pm
680 500 2X (-)
2pm to
10pm
(-) 230 1DC 1X
10pm to
6am
(-) 300 600 (-)
TOTAL
08-23-2013
6 am to 2
pm
610 150 200 (-)
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08-22-2013
6 am to 2
pm
580 320 1DC (-)
2pm to
10pm
300 400 1DC (-)
10pm to
6am
(-) 50 1DC (-)
TOTAL
24. 2pm to
10pm
(-) (-) (-) (-)
10pm to
6am
200 500 1DC 1X
TOTAL
LEGEND (*) = not monitored
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25. 25 | Page
BODY PARTS TECHNIQUES ACTUAL
FINDINGS
INTERPRETATION
July , 2013
Integument
A. Skin
Inspection and
palpation
Patient’s skin is brown in color
and uniform in all parts of the
body. Poor skin turgor.
Client is
dehydrated due
to insufficient
water
circulation in
the body.
B. Nails Inspection
and
Palpation
Nails are clean and not
trimmed with normal angle
curvature, and with a capillary
refill of more than 3 seconds.
Pale colored nailbeds.
Surrounding tissues were
intact; no lesions or lacerations
were observed.
Indicates poor
personal hygiene.
Patient has
insufficient
oxygen supply in
the blood.
Head Inspection
There is irregular form of head
shape.
This is due to
post operation
done to the
patient when he
is on his
childhood.
Mouth Inspection
There is tongue drooping to
the right. Voice is not well
modulated and with slurring
words when talking.
It indicates
_______________nerv
e impairment due
to stroke.
Ears Inspection
was able to hear whisper
spoken 2 feet away on the
right side. but not clearly
heard.
It indicates
impairment in
acoustic nerve
Chest and Lungs Inspection
The patient has abnormal
breathing pattern, with
respiratory rate of 28
cycles in one full minute
There is rapid
respiration to
compensate for the
needs of oxygen in
27. Lifestyle History/ Gordon's Functional Pattern
Patterns Before Diagnosis After Diagnosis
Health Perception and
Health Management
He can perform his daily activities
without fatigue and irritation. He is
smoker and a drinker. He lacks
knowledge regarding the importance
of proper compliance to medications
and the importance of hygiene
especially with his condition.
After knowing his condition
he felt easily fatigue and
irritated. He does not use
cigarettes and even alcohol.
He has knowledge on how to
take his medicines correctly.
Nutritional Metabolic
Pattern
He eats rice, vegetables and fish
regularly. Seldom eats pork and
chicken. He had normal appetite and
no fluctuations in weight. No
difficulty of swallowing was
expressed and no presence of
dentures. Can drinks 8-10 glasses a
day. And eats 3 meals a day with 2
snacks.
He followed his diet
prescription which is Low salt
low fat diet. He avoids eating
salty & fatty foods that can
affect on his condition.
Elimination Has a regular bowel movement and He defecates once a day with a
27 | Page
28. he defecates twice a day yellow to
brown colored formed stool and
seldom experienced
constipation/diarrhea. He urinates
approximately 5 times a day and
once at midnight, approximately
220cc per voiding.
brown colored formed stool.
Can experienced constipation.
Urinates 4 times a day and
once at midnight. He usually
has excessive sweating.
Activity/Exercise
Independent in performing self care
activities such as bathing, grooming,
toileting, eating. He can climb stairs
independently and ambulates
without assistance. He attends his
work in the morning at around 6 am
and returns home by 5 pm. During
weekends he spends his time
relaxing at home or doing simple
household repairs. He has no
exercise patterns, for him his
exercise is already included in his
work
He needs assistance in
performing self care activities
such as bathing, He felt easily
fatigue even just climb the
stairs. He stops working and
just stayed at home. Every
morning to walk at least 30
minutes is enough for him as
part of his daily exercise.
Sleep and Rest
He sleeps for 8-9 hours per day. He
goes to bed early at 10-10; 30 pm
and wakes up at 6; 00 am .He has no
schedules of AM or PM nap because
of his work. He experienced that he
feel rested after his sleep. He does
not have any trouble sleeping.
He sleeps 6 hours a day. He
has difficulty of going back on
sleep when he wakes up at
night. He just needs to listen to
music in order to make his
eyes tired.
Self Perception He is contended whatever he has
now and is thankful to God that still
he is able to attend to do his work.
Although he knows his
condition, he still has no
anxiety and fear about his
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29. He has a good body image of
himself and, maintains a happy
disposition and optimistic outlook
about the future.
condition and he accepts it. He
expressed a positive spirit
towards wellness.
Role/Relationship
He is separated with his years and
has a 2 children 1 girl and 1 boy. He
has a good relationship with his
family members especially with his
wife who accompanied him in the
hospital since the first day of
admission
He expressed his concerns
regarding his role as the
provider of their household
since his wife is unemployed.
He worries about the added
expenses for the medicines
and their expenses at home.
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30. Sexuality-Reproductive He was circumcised when he was 9
years old. Did not express any
problems with his sexuality and
contentment with his live-in as his
partner. He also expressed
contentment of having 2 children.
His first coitus was 17 years old.
After hospitalization he
doesn’t have any interest
sexual development.
Coping Stress and
Belief
Major concern regarding in his
hospitalization and his illness are the
expenses of his stay in the hospital
and his medication. Other concerns
are the unprovided needs of his
family in their household
Patient expressed that life
should still go on and they
should not lose hope for these
are only challenges in his
journey. Strong emotional
support from his live-in
partner and children also
empowers him to continuously
be strong. He exhibited strong
faith in God as he said that
everything that has happened
is according to God’s will and
decision.
Cognitive/Perceptual Alert, oriented, and has normal
speaking ability. He speaks few
Cebuano and fluent in Tagalog. He is
able to comprehend and
communicate effectively and has
appropriate interactive skills. His
eyes can see things clearly and his
not wearing eye glasses. He can hear
sounds clearly.
He cannot see things clearly in
a long distance but he’s still
not wearing glasses.
Values and Belief A Roman Catholic and has no
religious restrictions. He often goes
to church with his wife and always
expresses his strong faith to God as
his healer and provider.
He is contended of what God
has provided them and
surrenders everything
according to God’s will.
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31. LABORATORIES/ DIAGNOSTIC PROCEDURES
BLOOD TYPING
Blood typing is used to determine an individual's blood group and what type of blood or
blood components the person can safely receive. It is important to ensure that there is
compatibility between a person who requires a transfusion of blood or blood components and the
ABO and Rh type of the unit of blood that will be transfused. A potentially fatal transfusion
reaction can occur if a unit of blood containing an ABO antigen to which a person has
an antibody is transfused to that person.
Date: August 12, 2013
Blood Typing: “O”
Rh Typing: Positive
A. Routine Test
a.1. COMPLETE BLOOD COUNT
The CBC is one of the most common blood test. It’s often done as a part of a routine
check -up. The CBC can help detect diseases and disorders, such as Anemia, infection
also clotting problems, blood cancers and immune system disorders. This test also
measures many different parts of the blood.
DATE PERFORMED: August 12, 2013
TEST NORMAL
VALUE
RESULT IMPLICATION
31 | Page
32. Hemoglobin 120 – 160
g/L
145 There is no increase and decrease of hemoglobin of
the patient. It is within the normal range.
Hematocrit 0.36 - 0.47 0.43 There is no increase and decrease of hematocrit
of the patient. It is within the normal range.
RBC 4.5 – 6.5 x
10¹²/L
4.85 There is no increase and decrease of RBC of the
patient. It is within the normal range.
WBC 5 – 10 x
10 /L⁹
6.33 There is no increase and decrease of WBC of
patient. It is within the normal range.
DIFFERENTIAL COUNT
NEUTROPHILS
Lymphocytes 0.25-0.35 0.34 There is no increase and decrease of
lymphocytes of the patient. It is within the normal
range.
Monocytes 0.02-0.06 0.05 There is no increase and decrease of monocytes
of the patient. It is within the normal range.
Eosinophils 0.02 – 0.04 0.02 There is no increase and decrease of
eosinophils of the patient. It is within the normal
range.
32 | Page
33. Platelet count 1500 – x 10
³/ml³
204 There is no increase and decrease of platelet
count of the patient. It is within the normal range.
C. Confirmatory Test
A. BLOOD CHEMISTRY
Blood chemistry tests are often grouped together into profiles, or panels,
requiring one requisition and a single venous specimen. Tests performed include
glucose, electrolytes, enzymes, lipids, creatinine, and protein values.
A. DATE PERFORMED: August 12, 2013
TEST NORMAL
VALUES
RESULTS IMPLICATIONS
Sodium 135 - 148
mg/dL
138.0
There is no increase and decrease of
serum sodium of the patient. It is within
the normal range.
Potassium 3.50 - 5.30 2.96
There is a decrease of serum potassium of the
patient. It indicates hypokalemia
B. ECG (electrocardiogram)
Date Performed: August 12, 2013
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34. ECG (electrocardiogram) is a test that measures the electrical activity of the
heart. The heart is a muscular organ that beats in rhythm to pump the blood through
the body. The signals that make the heart's muscle fibres contract come from the
sinoatrial node, which is the natural pacemaker of the heart.
In an ECG test, the electrical impulses made while the heart is beating are
recorded and usually shown on a piece of paper. This is known as an
electrocardiogram, and records any problems with the heart's rhythm, and the
conduction of the heart beat through the heart which may be affected by underlying
heart disease.
INTERPRETATION:
NSSTTC
C. Roentgenologic Report
Date Performed: July 07, 2013
Radiology is a medical specialty that employs the use ofimaging to both diagnose and
34 | Page
35. treat disease visualized within the human body. Radiologists use an array of imaging
technologies such as X-ray radiography,ultrasound, computed tomography (CT), nuclear
medicine,positron emission tomography (PET) and magnetic resonance imaging (MRI) to
diagnose or treat diseases.Interventional radiology is the performance of (usuallyminimally
invasive) medical procedures with the guidance of imaging technologies.
Results:
> The lungs are clear
> Heart is enlarged in size
> The aortic knob is calcific
> The rest of the visualized structures are unremarkable.
D. CRANIAL CT-SCAN
Date Performed: January 19, 2013
35 | Page
36. FINDINGS: IMPRESSIONS:
> There is a focus of high-attenuation seen in
the right capsuloganglionic region, measuring
2.95 x 1.47 x 3.18 cm (7.17cc) with mild
associated mass effect.
> Small-hypodense focus is noted in the right
thalamus
> The gray-white matter interface is
maintained.
> There is no midline shift.
> The ventricles and cortical sulci are normal
in configuration.
> Basilar, bilateral vertebral & internal carotid
arteries are atherosclerotic.
> Visualized cerebellar hemisphere, pons,
pineal region, orbits, paranasal sinuses,
pestromastoids and bony calvarium are intact
with no demonstrable fracture.
> Acute intracerebral hemorrhage, Right
capsuloganglionic region (7.17 cc)
> Lacunar infarct, Right thalamus
> Atherosclerotic basilar, bilateral vertebral &
internal carotid arteries
36 | Page
37. ANATOMY AND PHYSIOLOGY OF THE NERVOUS SYSTEM
The nervous system is divided into the
• central nervous system (CNS) and the
• peripheral nervous system (PNS)
The CNS consists of the
• spinal cord and the
• brain
The PNS consists of
• sensory neurons running from stimulus receptors that inform the CNS of the
stimuli
• motor neurons running from the CNS to the muscles and glands -
called effectors - that take action.
CENTRAL NERVOUS SYSTEM
The spinal cord
• conducts sensory information from the peripheral nervous system (both
somatic and autonomic) to the brain
• conducts motor information from the brain to our various effectors
o skeletal muscles
o cardiac muscle
o smooth muscle
37 | Page
38. o glands
• serves as a minor reflex center
31 pairs of spinal nerves arise along the spinal cord. These are "mixed"
nerves because each contain both sensory and motor axons. However, within the spinal
column,
• all the sensory axons pass into the dorsal root ganglion where their cell
bodies are located and then on into the spinal cord itself.
• all the motor axons pass into the ventral roots before uniting with the sensory
axons to form the mixed nerves.
The spinal cord carries out two main functions:
• It connects a large part of the peripheral nervous system to the brain. Information
(nerve impulses) reaching the spinal cord through sensory neurons are
transmitted up into the brain. Signals arising in the motor areas of the brain travel
back down the cord and leave in the motor neurons.
• The spinal cord also acts as a minor coordinating center responsible for some
simple reflexes like the withdrawal reflex.
The interneurons carrying impulses to and from specific receptors and effectors are
grouped together in spinal tracts.
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39. Interneurons
These are found exclusively within the spinal cord and brain. They are stimulated by
signals reaching them from
• sensory neurons
• other interneurons or
• both.
Interneurons are also called association neurons.
It is estimated that the human brain contains 100 billion (1011
) interneurons averaging
1000 synapses on each; that is, some 1014
connections.
Crossing Over of the Spinal Tracts
Impulses reaching the spinal cord from the left side of the body eventually pass over to
tracts running up to the right side of the brain and vice versa. In some cases this
crossing over occurs as soon as the impulses enter the cord. In other cases, it does not
take place until the tracts enter the brain itself.
The brain
• receives sensory input from the spinal cord as well as from its own nerves
(e.g., olfactory and optic nerves)
• devotes most of its volume (and computational power) to processing its various
sensory inputs and initiating appropriate — and coordinated — motor outputs.
39 | Page
40. White Matter vs. Gray Matter
Both the spinal cord and the brain consist of
• white matter = bundles of axons each coated with a sheath of myelin
• gray matter = masses of the cell bodies and dendrites — each covered
with synapses.
In the spinal cord, the white matter is at the surface, the gray matter inside.
In the brain of mammals, this pattern is reversed. However, the brains of "lower"
vertebrates like fishes and amphibians have their white matter on the outside of their
brain as well as their spinal cord.
The Meninges
Both the spinal cord and brain are covered in three continuous sheets of connective
tissue, the meninges. From outside in, these are the
• dura mater — pressed against the bony surface of the interior of the vertebrae
and the cranium
• the arachnoid
• the pia mater
The region between the arachnoid and pia mater is filled with cerebrospinal
fluid (CSF).
The Extracellular Fluid (ECF) of the Central Nervous System
The cells of the central nervous system are bathed in a fluid that differs from that serving
as the ECF of the cells in the rest of the body.
40 | Page
41. • The fluid that leaves the capillaries in the brain contains far less protein than
"normal" because of the blood-brain barrier, a system of tight junctions between
the endothelial cells of the capillaries. This barrier creates problems in medicine
as it prevents many therapeutic drugs from reaching the brain.
• cerebrospinal fluid (CSF), a secretion of the choroid plexus. CSF flows
uninterrupted throughout the central nervous system
o through the central cerebrospinal canal of the spinal cord and
o through an interconnected system of four ventricles in the brain.
CSF returns to the blood through veins draining the brain
The Brain
The brain of all vertebrates develops from three swellings at the anterior end of
the neural tube of the embryo. From front to back these develop into the
• forebrain (also known as the prosencephalon — shown in light color)
• midbrain (mesencephalon — gray)
• hindbrain (rhombencephalon — dark color) The human brain is shown from
behind so that the cerebellum can be seen.
41 | Page
42. The human brain receives nerve impulses from
• the spinal cord and
• 12 pairs of cranial nerves
o Some of the cranial nerves are "mixed", containing both sensory and
motor axons
o Some, e.g., the optic and olfactory nerves (numbers I and II) contain
sensory axons only
o Some, e.g. number III
that controls eyeball
muscles, contain motor
axons only.
The Hindbrain
The main structures of the hindbrain
(rhombencephalon) are the
• medulla oblongata
• pons and
• cerebellum
Medulla oblongata
The medulla looks like a swollen tip to the spinal cord. Nerve impulses arising here
• rhythmically stimulate the intercostal muscles and diaphragm — making
breathing possible.
• regulate heartbeat
• regulate the diameter of arterioles thus adjusting blood flow.
The neurons controlling breathing have mu (µ) receptors, the receptors to
which opiates, like heroin, bind. This accounts for the suppressive effect of opiates on
breathing.] Destruction of the medulla causes instant death.
42 | Page
43. Pons
The pons seems to serve as a relay station carrying signals from various parts of the
cerebral cortex to the cerebellum. Nerve impulses coming from the eyes, ears,
and touch receptors are sent on the cerebellum. The pons also participates in the
reflexes that regulate breathing.
The reticular formation is a region running through the middle of the hindbrain (and on
into the midbrain). It receives sensory input (e.g., sound) from higher in the brain and
passes these back up to the thalamus. The reticular formation is involved in sleep,
arousal (and vomiting).
Cerebellum
The cerebellum consists of two deeply-convoluted hemispheres. Although it represents
only 10% of the weight of the brain, it contains as many neurons as all the rest of the
brain combined.
Its most clearly-understood function is to coordinate body movements. People with
damage to their cerebellum are able to perceive the world as before and to contract their
muscles, but their motions are jerky and uncoordinated.
So the cerebellum appears to be a center for learning motor skills (implicit memory).
Laboratory studies have demonstrated both long-term potentiation (LTP) and long-term
depression (LTD) in the cerebellum.
The Midbrain
The midbrain (mesencephalon) occupies only a small region in humans (it is relatively
much larger in "lower" vertebrates). We shall look at only three features:
• the reticular formation: collects input from higher brain centers and passes it on
to motor neurons.
• the substantia nigra: helps "smooth" out body movements; damage to the
substantia nigra causes Parkinson's disease.
43 | Page
44. • the ventral tegmental area (VTA): packed with dopamine-releasing neurons
that
o are activated by nicotinic acetylcholine receptors and
o whose projections synapse deep within the forebrain.
The VTA seems to be involved in pleasure: nicotine, amphetamines and cocaine
bind to and activate its dopamine-releasing neurons and this may account — at
least in part— for their addictive qualities.
The midbrain along with the medulla and pons are often referred to as the "brainstem".
The Forebrain
The human forebrain (prosencephalon) is made up of
• a pair of large cerebral hemispheres, called the telencephalon. Because of
crossing over of the spinal tracts, the left hemisphere of the forebrain deals with
the right side of the body and vice versa.
• a group of structures located deep within the cerebrum, that make up
the diencephalon.
Diencephalon
We shall consider four of its structures: the
• Thalamus.
o All sensory input (except for olfaction) passes through these paired
structures on the way up to the somatic-sensory regions of the cerebral
cortex and then returns to them from there.
o signals from the cerebellum pass through them on the way to the motor
areas of the cerebral cortex.
• Lateral geniculate nucleus (LGN). All signals entering the brain from each optic
44 | Page
45. nerve enter a LGN and undergo some processing before moving on the various
visual areas of the cerebral cortex.
• Hypothalamus.
o The seat of the autonomic nervous system. Damage to the hypothalamus
is quickly fatal as the normal homeostasis of body temperature, blood
chemistry, etc. goes out of control.
o The source of 8 hormones, two of which pass into the posterior lobe of
the pituitary gland.
o
• Posterior lobe of the pituitary.
Receives
o vasopressin and
o oxytocin
from the hypothalamus and releases them into the blood.
The Cerebral Hemispheres
Each hemisphere of the cerebrum
is subdivided into four
lobes visible from the outside:
• frontal
• parietal
• occipital
• temporal
Hidden beneath these regions
of each cerebral cortex is
• an olfactory bulb; they receive input from the olfactory epithelia.
45 | Page
46. • a striatum; they receive input from the
frontal lobes and also from the limbic system
(below). At the base of each striatum is a
• nucleus accumbens (NA).
The pleasurable (and addictive) effects of
amphetamines, cocaine, and perhaps other
psychoactive drugs seem to depend on their
producing increasing levels of dopamine at the
synapses in the nucleus accumbens (as well as the VTA).
a limbic system; they receives input from various association areas in the cerebral
cortex and pass signals on to the nucleus accumbens. Each limbic system is made up
of a:
o hippocampus. It is essential for the formation of long-term memories.
o an amygdala
The amygdala appears to be a center of emotions (e.g., fear). It sends signals to the
hypothalamus and medulla which can activate the flight or fight response of
the autonomic nervous system.
In rats, at least, the amygdala contains receptors for
vasopressin whose activation increases aggressiveness and other signs of the flight or
fight response;
oxytocin whose activation lessens the signs of stress.
The amygdala receives a rich supply of signals from the olfactory system, and this may
account for the powerful effect that odor has on emotions (and evoking memories).
Hormones of the Pituitary
The pituitary gland is pea-sized structure located at the base of the brain. In humans, it
46 | Page
47. consists of two lobes:
• the Anterior Lobe and
• the Posterior Lobe
The Anterior Lobe
The anterior lobe contains six types of secretory cells, all but one of which are
specialized to secrete only one of the anterior lobe hormones. All of them secrete their
hormone in response to hormones reaching them from the hypothalamus of the brain.
Thyroid Stimulating Hormone (TSH)
TSH (also known as thyrotropin) is a glycoprotein consisting of:
• a beta chain of 118 amino acids and
• an alpha chain of 92 amino acids. The alpha chain is identical to that found in
two other pituitary hormones, FSH and LH as well as in the hormone chorionic
gonadotropin. Thus it is its beta chain that gives TSH its unique properties.
The secretion of TSH is
• stimulated by the arrival of thyrotropin releasing hormone (TRH) from the
hypothalamus.
• inhibited by the arrival of somatostatin from the hypothalamus.
As its name suggests, TSH stimulates the thyroid gland to secrete its
hormone thyroxine (T4). It does this by binding to transmembrane G-protein-coupled
receptors (GPCRs) on the surface of the cells of the thyroid.
Follicle-Stimulating Hormone (FSH)
FSH is a heterodimeric glycoprotein consisting of
• the same alpha chain found in TSH (and LH)
• a beta chain of 118 amino acids, which gives it its unique properties.
47 | Page
48. Synthesis and release of FSH is triggered by the arrival from the hypothalamus
of gonadotropin-releasing hormone (GnRH). The effect of FSH depends on one's sex.
FSH in females
In sexually-mature females, FSH (assisted by LH) acts on the follicle to stimulate it to
release estrogens.
FSH produced by recombinant DNA technology (Gonal-f®) is available to promote
ovulation in women planning to undergo in vitro fertilization (IVF) and other forms of
assisted reproductive technology.
FSH in males
In sexually-mature males, FSH acts on spermatogonia stimulating (with the aid
of testosterone) the production of sperm.
Luteinizing Hormone (LH)
LH is synthesized within the same pituitary cells as FSH and under the same stimulus
(GnRH). It is also a heterodimeric glycoprotein consisting of
• the same 92-amino acid alpha subunit found in FSH and TSH (as well as
in chorionic gonadotropin);
• a beta chain of 121 amino acids that is responsible for its properties.
The effects of LH also depend on sex.
LH in females
In sexually-mature females,
• a surge of LH triggers the completion of meiosis I of the egg and its release
(ovulation) in the middle of the menstrual cycle;
• stimulates the now-empty follicle to develop into the corpus luteum, which
secretes progesterone during the latter half of the menstrual cycle.
Women with a severe LH deficiency can now be treated with human LH (Luveris®)
48 | Page
49. produced by recombinant DNA technology.
LH in males
LH acts on the interstitial cells (also known as Leydig cells) of the testes stimulating
them to synthesize and secrete the male sex hormone, testosterone.
LH in males is also known as interstitial cell stimulating hormone (ICSH).
Prolactin (PRL)
Prolactin is a protein of 198 amino acids. During pregnancy it helps in the preparation of
the breasts for future milk production.
After birth, prolactin promotes the synthesis of milk.
Prolactin secretion is
• stimulated by TRH
• repressed by estrogens and dopamine.
In pregnant mice, prolactin stimulates the growth of new neurons in the olfactory
center of the brain.
Growth Hormone (GH)
Human growth hormone (HGH; also called somatotropin) is a protein of 191 amino
acids. The GH-secreting cells are stimulated to synthesize and release GH by the
intermittent arrival of growth hormone releasing hormone (GHRH) from the
hypothalamus. GH promotes body growth by:
• binding to receptors on the surface of liver cells.
• This stimulates them to release insulin-like growth factor-1 (IGF-1; also known
as somatomedin)
• IGF-1 acts directly on the ends of the long bones promoting their growth
49 | Page
50. ACTH — the adrenocorticotropic hormone
ACTH is a peptide of 39 amino acids. It is cut from a larger
precursor proopiomelanocortin (POMC).
ACTH acts on the cells of the adrenal cortex, stimulating them to produce
• glucocorticoids, like cortisol;
• mineralocorticoids, like aldosterone;
• androgens (male sex hormones, like testosterone).
• In the fetus, ACTH stimulates the adrenal cortex to synthesize a precursor of
estrogen called dehydroepiandrosterone sulfate (DHEA-S) which helps
prepare the mother for giving birth.
Production of ACTH depends on the intermittent arrival of corticotropin-releasing
hormone (CRH) from the hypothalamus.
Hypersecretion of ACTH is a frequent cause of Cushing's disease.
The Posterior Lobe
The posterior lobe of the pituitary releases two hormones, both synthesized in the
hypothalamus, into the circulation.
Vasopressin
Vasopressin is a peptide of 9 amino acids (Cys-Tyr-Phe-Gln-Asn-Cys-Pro-Arg-Gly). It is
also known as arginine vasopressin (AVP) and the antidiuretic hormone (ADH).
50 | Page
51. Vasopressin acts on the collecting ducts of the kidney to facilitate the reabsorption of
water into the blood. This it acts to reduce the volume of urine formed (giving it its name
of antidiuretic hormone).
leads to excessive loss of urine, a condition known as diabetes insipidus. The most
severely-afflicted patients may urinate as much as 30 liters (almost 8 gallons!) of urine
each day. The disease is accompanied by terrible thirst, and patients must continually
drink water to avoid dangerous dehydration.
Oxytocin
Oxytocin is a peptide of 9 amino acids (Cys-Tyr-Ile-Gln-Asn-Cys-Pro-Leu-Gly).
It acts on certain smooth muscles:
o stimulating contractions of the uterus at the time of birth;
o stimulating release of milk when the baby begins to suckle.
Oxytocin is often given to prospective mothers to hasten birth.
Oxytocin also acts on the nucleus accumbens and amygdala in the brain where it
enhances:
• bonding between males and females after they have mated;
• bonding between a mother and her newborn;
• and, in humans, increases the level of one's trust in other people.
PERIPHERAL NERVOUS SYSTEM
The peripheral nervous
system is subdivided into the
• somatic nervous
51 | Page
52. system and the
• autonomic nervous system
The Somatic Nervous System
The sensory-somatic system consists of
• 12 pairs of cranial nerves and
• 31 pairs of spinal nerves.
The Cranial Nerves
Nerves Type Function
I
Olfactory
sensory olfaction (smell)
II
Optic
sensory
vision
(Contain 38% of all the axons connecting to the brain.)
III
Oculomotor
motor* eyelid and eyeball muscles
IV
Trochlear
motor* eyeball muscles
V
Trigeminal
mixed
Sensory: facial and mouth sensation
Motor: chewing
VI
Abducens
motor* eyeball movement
VII
Facial
mixed
Sensory: taste
Motor: facial muscles and
salivary glands
VIII
Auditory
sensory hearing and balance
IX
Glossopharyngeal
mixed
Sensory: taste
Motor: swallowing
52 | Page
53. X
Vagus
mixed
main nerve of the
parasympathetic nervous system (PNS)
XI
Accessory
motor swallowing; moving head and shoulder
XII
Hypoglossal
motor* tongue muscles
Note: These do contain a few sensory neurons that bring back signals from the muscle
spindles in the muscles they control.
The Spinal Nerves
All of the spinal nerves are "mixed"; that is, they contain both sensory and motor
neurons.
All our conscious awareness of the external environment and all our motor activity to
cope with it operate through the sensory-somatic division of the PNS.
The Autonomic Nervous System
The autonomic nervous system consists of
sensory neurons and motor neurons that run
between the central nervous system (especially
the hypothalamus and medulla oblongata) and
various internal organs such as the:
• heart
• lungs
• viscera
• glands (both exocrine and endocrine)
It is responsible for monitoring conditions in the
internal environment and bringing about
appropriate changes in them. The contraction of both smooth muscle and cardiac
muscle is controlled by motor neurons of the autonomic system.
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54. The actions of the autonomic nervous system are largely involuntary (in contrast to
those of the sensory-somatic system). It also differs from the sensory-somatic system is
using two groups of motor neurons to stimulate the effectors instead of one.
• The first, the preganglionic neurons, arise in the CNS and run to a ganglion in
the body. Here they synapse with
• postganglionic neurons, which run to the effector organ (cardiac muscle,
smooth muscle, or a gland).
The autonomic nervous system has two subdivisions, the
• sympathetic nervous system and the
• parasympathetic nervous system.
The Sympathetic Nervous System
The preganglionic motor
neurons of the sympathetic
system (shown in black)
arise in the spinal cord.
They pass into
sympathetic ganglia which
are organized into two
chains that run parallel to
and on either side of the
spinal cord.
54 | Page
55. The preganglionic neuron may do one of three things in the sympathetic ganglion:
• synapse with postganglionic neurons (shown in white) which then reenter the
spinal nerve and ultimately pass out to the sweat glands and the walls of blood
vessels near the surface of the body.
• pass up or down the sympathetic chain and finally synapse with postganglionic
neurons in a higher or lower ganglion
• leave the ganglion by way of a cord leading to special ganglia (e.g. the solar
plexus) in the viscera. Here it may synapse with postganglionic sympathetic
neurons running to the smooth muscular walls of the viscera. However, some of
these preganglionic neurons pass right on through this second ganglion and into
the adrenal medulla. Here they synapse with the highly-modified postganglionic
cells that make up the secretory portion of the adrenal medulla.
The neurotransmitter of the preganglionic sympathetic neurons is acetylcholine (ACh).
It stimulates action potentials in the postganglionic neurons.
The neurotransmitter released by the postganglionic neurons is noradrenaline (also
called norepinephrine).
The action of noradrenaline on a particular gland or muscle is excitatory is some cases,
inhibitory in others. (At excitatory terminals, ATP may be released along with
noradrenaline.)
The release of noradrenaline
• stimulates heartbeat
• raises blood pressure
• dilates the pupils
• dilates the trachea and bronchi
55 | Page
56. • stimulates glycogenolysis — the conversion of liver glycogen into glucose
• shunts blood away from the skin and viscera to the skeletal muscles, brain, and
heart
• inhibits peristalsis in the gastrointestinal (GI) tract
• inhibits contraction of the bladder and rectum
• and, at least in rats and mice, increases the number of AMPA receptors in the
hippocampus and thus increases long-term potentiation (LTP).
In short, stimulation of the sympathetic branch of the autonomic nervous system
prepares the body for emergencies: for "fight or flight" (and, perhaps, enhances the
memory of the event that triggered the response).
Activation of the sympathetic system is quite general because
• a single preganglionic neuron usually synapses with many postganglionic
neurons;
• the release of adrenaline from the adrenal medulla into the blood ensures that all
the cells of the body will be exposed to sympathetic stimulation even if no
postganglionic neurons reach them directly.
The Parasympathetic Nervous System
The main nerves of the parasympathetic system are the tenth cranial nerves, the vagus
nerves. They originate in the medulla oblongata. Other preganglionic parasympathetic
neurons also extend from the brain as well as from the lower tip of the spinal cord.
Each preganglionic parasympathetic neuron synapses with just a few postganglionic
neurons, which are located near — or in — the effector organ, a muscle or
gland. Acetylcholine (ACh) is the neurotransmitter at all the pre- and many of the
postganglionic neurons of the parasympathetic system. However, some of the
postganglionic neurons release nitric oxide (NO) as their neurotransmitter.
56 | Page
57. The Nobel Prize winning
physiologist Otto Loewi
discovered (in 1920) that
the effect of both
sympathetic and
parasympathetic
stimulation is mediated by
released chemicals. He
removed the living heart
from a frog with its
sympathetic and
parasympathetic nerve
supply intact. As expected,
stimulation of the first
speeded up the heart while
stimulation of the second
slowed it down.
Loewi found that these two responses would occur in a second frog heart supplied with a
salt solution taken from the stimulated heart. Electrical stimulation of the vagus nerve
leading to the first heart not only slowed its beat but, a short time later, slowed that of the
second heart also. The substance responsible was later shown to be acetylcholine.
During sympathetic stimulation, adrenaline (in the frog) is released.
Parasympathetic stimulation causes
• slowing down of the heartbeat (as Loewi demonstrated)
• lowering of blood pressure
• constriction of the pupils
• increased blood flow to the skin and viscera
• peristalsis of the GI tract
In short, the parasympathetic system returns the body functions to normal after they
57 | Page
58. have been altered by sympathetic stimulation. In times of danger, the sympathetic
system prepares the body for violent activity. The parasympathetic system reverses
these changes when the danger is over.
The vagus nerves also help keep inflammation under control. Inflammation stimulates
nearby sensory neurons of the vagus. When these nerve impulses reach the medulla
oblongata, they are relayed back along motor fibers to the inflamed area. The
acetylcholine from the motor neurons suppresses the release of inflammatory cytokines,
e.g., tumor necrosis factor (TNF), from macrophages in the inflamed tissue.
Although the autonomic nervous system is considered to be involuntary, this is not
entirely true. A certain amount of conscious control can be exerted over it as has long
been demonstrated by practitioners of Yoga and Zen Buddhism. During their periods of
meditation, these people are clearly able to alter a number of autonomic functions
including heart rate and the rate of oxygen consumption. These changes are not simply
a reflection of decreased physical activity because they exceed the amount of change
occurring during sleep or hypnosis.
58 | Page
59. COLLABORATIVE MANAGEMENT
SYMPTOMATIC APPROACH
SIGNS AND SYMPTOMS MEDICAL
MANAGEMENT
NURSING MANAGEMENT
Weakness (hemiparesis) or paralysis
(hemiplegia) on one side of the
body.
Assessed the patient degree of
weakness both upper and
lower extremities using
muscle strength and functional
level.
Assess ability: to move and
change position, to transfer
and walk, for fine muscle
movement and fro gross
muscle movement.
Determine active and passive
range of motion capabilities.
Perform active and passive
ROM exercises in all
extremities several times
daily.
Change position at least
ONCE every two hours
Administer citicoline 10mg/tab
O.D
For cranial CT scan plain.
Closely monitored for any
untoward manifestations.
Spasticity, stiffness in the muscle or
painful muscle spasm
Provided safety measures by
using pillows on the side if
side rail is not available.
Administered Ketorolac
30mg TIV as ordered.
Administer Ketorolac 30mg
TIV.
For cranial CT scan plain.
Closely monitored for any
untoward manifestations.
Problem with balance and
coordination
Provided safety measures by
using pillows on the side if
side rail is not available.
For cranial CT scan plain.
59 | Page
60. Closely monitored for any
untoward manifestations.
Inability to swallow (Dysphagia) Prepared for Osteorize
feedings through NGT tube as
ordered;
Checked the patency of the
NGT tube.
Elevated the head of bed
during feedings, check tube
position before feeding,
administer feeding slowly.
Monitored and reported
excessive retained or residual
feeding.
WOF: Coffee ground GI
drainage.
Insert NGT tube
Give osteorize feeding
1,800kcal.
WOF: Vomiting
Closely monitored for any
untoward manifestations.
Paresthesia, numbness or odd
sensations
Assessed pt’s ability to sense
light touch, pinprick, and
temperature. Touch skin
lightly with a pin, cotton ball
or hot/cold object and ask
patient to describe sensation
and point to where touch
occurred.
Using pt’s toes or fingers,
assess position sense (ability
to sense whether the joint is
moved in an upward or
downward position)
Perform regular skin
inspections and instruct pt in
techniques to do the same.
Explain consequences of
prolonged pressure on the
skin.
Provide tactile stimulation to
affected limbs using rough
cloth or hand.
For cranial CT-scan plain.
Closely monitored for any
untoward manifestations.
60 | Page
61. Instruct pt to regularly move
affected limbs
Problem with memory, thinking,
attention or learning, Slurring of
words
Modulate personal
communication, controlling
body language and providing
clear, simple directions.
Allow adequate time for
patient response.
Provide opportunities for
spontaneous conversation.
Anticipate pts needs until
alternative means of
communication can be
established.
Provide reality orientation and
focus attention, but avoid
constantly correcting errors.
For Cranial CT scan plain.
To refferal for rehab.
Problems using language; knowing
the right words but having trouble
saying them correctly. (Dysarthria)
Make the atmosphere
conducive to communication,
Provided strong emotional
support and understanding
to allay anxiety; avoid
completing patient’s
sentences.
Be consistent in schedule,
routines, and repetitions.
Speak slowly and in a calm
manner, and give one
instruction at a time;
allow patient time to process.
Make referral for home speech
therapy.
Problems with bowel or bladder
control
Monitored vital signs q1h.
Monitored intake and output.
Frequent assessed the Urine
output. Its color,
characteristics.
Insert Indwelling folley catheter.
Give Mannitol 200 mg TIV
Administer Furosimide 20 mg
TIV.
61 | Page
62. Ensure that the IFC is intact. Give Lactulose 30cc OD.
confusion
Dizziness Assess the patient’s
neurologic status; observe for
CVA progression and level of
consciousness
(LOC) change as evidenced by
decreasing numerical score on
the GLASGOW COMA
SCALE.
Provided safety measures
using pillow inside the patient
if side rail is not available.
Administer cinarrizine 25mg P.O
to reduce dizziness.
Closely monitored for any
untoward manifestations.
Fatigue Monitored vital signs q1h.
Assessed the patient’s
neurologic status; observe for
CVA progression and level of
consciousness
(LOC) change as evidenced by
decreasing numerical score on
the GLASGOW COMA
SCALE.
Provided safety measures
using pillow inside the patient
if side rail is not available.
Administer Administer citicoline
10mg/tab O.D
ECG Changes
Result: sinus tachycardia
Monitored the patient’s vital
signs every 1 hour.
Monitor arterial blood gases
and pulse oximetry.
Reviewed laboratory and
diagnostic test such as
ECG.
Instructed the patient to rest.
For repeat 12L ECG.
Give Hydroxyzine 25
mg/tab
STAT
Hypokalemia Monitored the patients vital
signs every 1 hour.
Monitored intake and output.
Reviewed laboratory and
Administer Kalium Durule 1 tab,
OD
Watch out for tachycardia.
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