Father Saturnino Urios University

San Francisco St. Butuan City 8600,

Region XIII Caraga, Philippines
NURSING PROGRAM

A Mini Patient Analytical Report Presentation:

STROKE, BILATERAL
POSTERIOR CIRCULATION
INFARCTION,
CARDIOEMBOLIC ARTERIAL
FIBRILLATION
THEME:
“LOVE YOUR HEART AND HELP YOUR BRAIN”

March 9-11; 16 -18, 2023

St. Anthony Nursing Unit, Manuel J. Santos Hospital, Butuan City

Calo, Nica Monette

Canonio, Kathleen Marie Enoy
Catabas, Nixie Skyler
Cloma, Therese Yzabel Bacsin
Cobelo, Ranilyn Magallanes
Colinares, Jonel Salomon
Dacpano, Ma. Kristine Ruaya
Daraman, Ruben III Quisto
De Vera, Francar Jade Mero
De Vera, Jean Ladesma

Level III Group 10 - Student Nurse

Moses Regie S. Caballero, RN

Supervising Clinical Instructor
INTRODUCTION

A stroke, sometimes called a brain attack, occurs when something blocks blood
supply to part of the brain or when a blood vessel in the brain bursts. In either case,
parts of the brain become damaged or die. A stroke can cause lasting brain damage,
long-term disability, or even death. The brain is the organ that manages our bodily
activities, retains our memories, and generates our ideas, feelings, and verbal
expression. In addition, the brain regulates a variety of bodily processes, including
respiration and digestion. We need oxygen for our brain to function properly. All the
areas of our brain receive oxygen-rich blood from your arteries. Brain cells begin to
die within minutes of a blockage in blood flow because they are unable to receive
oxygen, this causes a stroke.

There are two common types of stroke, Ischemic stroke and Haemorrhagic
stroke. Ischemic stroke occurs when blood clots or particles block the blood vessels
to the brain. Fatty deposits called plaque can also cause blockages by building up in
the blood vessels. Haemorrhagic stroke happens when an artery in the brain ruptures.
The leaked blood puts too much pressure on brain cells, which can cause damage.

A Cardioembolic stroke is a form of an Ischemic stroke. An ischemic stroke

involves obstructed blood vessels in the brain. The symptoms of a stroke can develop
very suddenly and may include:

• Numbness in the arm, leg, or face, often affecting one side of the body
• Confusion
• Speaking difficulties or difficulty understanding speech
• Vision difficulties in one or both eyes
• Difficulties with walking, coordination, balance, and dizziness
• Severe headache

Risk Factor for Cardioembolic Stroke

• Atrial fibrillation: Where a person has a slightly irregular and fast heartbeat. It
affects approximately 33 million people worldwide. Atrial fibrillation is the most
common cause of cardioembolic stroke.
• Systolic heart failure: The left ventricle of the heart becomes weak and does
not contract properly. People with systolic heart failure may have a higher risk
of stroke.
• Heart disease: A person with heart disease such as Coronary Artery Disease
is at higher risk for developing a cardioembolic stroke.
• Patent foramen ovale: Also known as a hole in the heart, patent foramen ovale
may be present in approximately 40% of people who have a stroke without a
known cause.
• Various other heart conditions or previous heart surgeries may also put a
person at risk of developing a cardioembolic stroke.

Modifiable Risk Factor • Physical inactivity

• High blood pressure Non-modifiable Risk Factor
• Diabetes • 55-years-old and above
• High cholesterol
• Smoking
• Viral infections
• Inflammatory conditions
Prevalence of Cardioembolic Strokes
Approximately 20% of ischemic strokes are considered cardioembolic. The
annual incidence is estimated at approximately 146,000 cases. In recent years, there
has been an increased prevalence of cardioembolic stroke compared to stroke from
large-artery atherosclerosis in high-income countries.
The risk of a cardioembolic event increases with age. The older the cohort, the
higher the estimated frequency of cardioembolic stroke because of the rapidly
increasing prevalence of atrial fibrillation in elderly persons. Elderly women are
particularly affected, whereas Black and Hispanic have a lower frequency of
cardioembolic strokes than white persons, reflecting the respective prevalence of atrial
fibrillation among these groups.
The Philippines has a population of 109 million and only 5.7% are above age
65 years old. Despite the young population, stroke remains a fatal disease and the
second cause of death. Even with the advances in science and introduction of
government health programs, the mortality remains high. With paucity of good
epidemiologic data, the real burden of disease is still not known. While the annual
stroke mortality in the country is reported in 2021, despite the COVID pandemic, the
recorded annual Philippine stroke death was 68,180, increased from 64,381 in 2020,
the number of stroke survivors with the disability has not been evaluated (Front.
Neurol.,2022)
Prevention of systemic embolism to occur again is achieved by means of
restoration and control of sinus rhythm or with permanent anti-thrombotic treatment.
The best way to help prevent a stroke is to eat a healthy diet, exercise regularly, and
avoid smoking and drinking too much alcohol. These lifestyle changes can reduce the
risk of problems like Atherosclerosis.
We, the group 10 level 3 nursing students were exposed to the Medical Surgical
Ward at Manuel J. Santos Hospital under Perception and Coordination Clinical Focus
Rotation. We chose this case in acquiring additional knowledge and skills in handling
patients with problems of Perception and Coordination. We would like to have a
deeper understanding regarding the case and be able to trace the progress of our
patient’s condition after the interventions that was done to her, considering that stroke
cases are rampant in our country. By doing so, we gained more knowledge at the
same time, we can be able to educate and spread awareness with regards to its cause,
treatment and management.
DEFINITION OF TERMS

• Acute Disseminated Encephalomyelitis (ADM) – A neurological disorder

characterized by brief but widespread attacks of inflammation in the brain and
spinal cord that damages the myelin.
• Posterior Circulation Ischemic Stroke – Posterior circulation stroke can present
with vertigo, ataxia, vomiting, headache, cranial nerve abnormalities, bilateral long
tract neurological sign, “locked in” syndrome or impaired consciousness, and
complex ocular signs or cortical blindness.
• Cardioembolic stroke – Defined as the presence of a potential intracardiac
source of embolism in the absence of cerebrovascular disease in a patient with
non-lacunar stroke. It is responsible for approximately 20% of all ischemic strokes.
NURSING HEALTH HISTORY

History-taking is an essential part of assessment and planning for the actions

to be taken to ensure the delivery of safe and quality patient care, and effective clinical
decision making (Ohm, et.al., 2013). This also allows for the nurse to look at other
areas apart from the physiological, and allows for a more wholesome approach to
understanding and providing nursing care. Nursing health history encompasses not
only biographical and medical data/history, but also that psychosocial and lifestyle-
related information, which may prove to be helpful in determining both present or
possible illnesses and risk factors, and in the prioritization of later-identified problems.
The nursing health history herein will encompass both the client’s history prior
to admission, and health history according to Gordon’s 11 Functional Health Patterns.
The utilization of Gordon’s Functional Health Patterns will aid in investigating the
health-related behaviors our client usually engages in and also in determining the
development of care and appropriate treatment to be rendered.
The gathered Information about the patient were all from the patient’s record
and verbalization of the identified persona. By means of gathering data from the
patient and her Daughter, the group applied ethical principles in nursing such as
confidentiality as it helps to build and develop trust between the student nurses and
the client. To preserve the client’s privacy and confidentiality, the student nurses,
therefore, withhold the real name of the subject. Thus, the student nurses hereby call
the client under the pseudonym of Patient P.
On the second day of Our exposure, we were able to choose a befitting client
for our Mini Patient Analytic Report Presentation with a diagnosis Stroke, Bilateral
Posterior Circulation Infarction, Cardioembolic Arterial Fibrillation. The initial physical
assessment and history taking were conducted last March 10, 2023, and were
completed on March 10, 2023.

Demographic Profile
Patient P, is a 69-year-old woman, of Filipino descent, Married, and has 5
Children. She weighs 60 kilos and stands 5 feet and 2 inches, Protestant by faith, born
on June, 22, 1953 She finish 3rd year college and is currently residing in Obrero,
Butuan City, Agusan del Norte. Furthermore, Patient P lives with her husband, 2
children and grandchildren, she is dependent with her children. Before the admission,
Patient P is a housewife with a small sari-sari store built in their home by her children.
Currently, her children are the one financing her medication and other needs.
Furthermore, Patient P is the one who goes to the market to buy supplies for her store,
but she was advised by her children to stop going alone or even buying supplies since
she often gets dizzy.

Family History
According to Patient P, both of her parents are hypertensive and almost all of
his siblings has Low Potassium level.
Past Health History
Patient P claims that she seldom gets sick when she was younger, stating, “dili
man ko dali masakit tong bata pako kay aktibo man ko tapos sige sab mig kaon ug
gulay sa balay.”. Furthermore, she stated that her childhood diet was nutritious since
vegetables and fruits were included in every meal. She was immunized with Covid
Vaccine. In terms of her childhood immunization, Patient P had no idea if she was
immunized or not stating that, “Wala ko kadumdom ug na bakunahan ko sauna kay
wa pamana nauso sa amoang panahon.”. Patient P is non- smoker and non-alcoholic.
Patient P is hypertensive and often gets dizzy that’s why her children had her check
to a Doctor who specialize in Neurology. Patient P was also admitted before, and they
found out that her heart was enlarged. Furthermore, she often visits her Doctor for a
regular check-up. Patient P has no known drug or food allergies.

History of Present Illness

Patient P was not feeling well before admission and complains of feeling dizzy
and headache. Before deciding to bring Patient P in the Hospital, her daughter told us
that “Gidala sa namo si Mama sa binisaya nga manambalay kay sa mga tinuohan lagi
unya nakulbaan me kay dili man usual ang kaluya ni Mama ug grabe gihapon ka labad
iyang ulo.” But there were no changes with Patient P’s condition that’s why they rushed
her to Manuel J Santos Hospital ER department on March 6 2023 at exactly 9:27 PM.
Patient P is in for admission due to severe headache and dizziness. Based on the
patient’s chart, upon admission, Patient P arrived conscious, awake, and coherent
upon interaction and she obeys commands; and is oriented to person, place, and time.
During the assessment of the student nurses, the patient was feeling better and was
able to respond to questions, she was also lively upon interaction and shows signs of
comfort upon the interview. Furthermore, the patient was advised to rest and prevent
movements that may cause dizziness.

Course of Treatment
On March 6, 2023 at 9: 27 PM, Patient P was admitted to Manuel J Santos
Hospital and came in from the emergency room with a chief complaint of severe
headache and dizziness. She was placed in bed with presenting symptoms of
headache. She underwent a series of assessments and has an admitting diagnosis of
ADM, Stroke. With initial vital signs as follows:
• Temperature: 36.6°C
• Pulse Rate: 62 bpm
• Respiratory Rate: 21 cpm
• Blood Pressure: 140/80
• Oxygen Saturation: 97%

Patient P has a final diagnosis of ADM Stroke, Posterior Bilateral Circulation

Infarction, Cardioembolic Arterial Fibrillation.
Seen and examined by Dr. D with orders carried out by the staff nurse:

DATE DOCTORS ORDER

➢ Diet: Full Diet
➢ VS q 2 hours
➢ I & O q shift
➢ Start IVF with PNSS 1L 10gtts/min
➢ Labs:

CBC
Electrolyte Panel C (Na K)
Admitting Orders:
Alanine Aminotransferase (ALT/GPT)
March 6, 2023
Troponin T & I
Lipid Profile
Uric Acid
Creatinine
Fasting Blood Sugar
Capillary Blood Glucose
12 Lead Electrocardiogram
Posterior – Anterior Chest X-ray
➢ Medications

March 6, 2023 Serc 24mg 1-tab TD

Stugeron 75mg 1-tab OD
Amlodipine 5mg 1-tab OD
➢ IVK & ff: PLR 1L + 40 meqs KCL x 16 hours x 4
March 7, 2023 cycle
➢ Kaligen 1-tab TID
GORDON’S 11 FUNCTIONAL HEALTH PATTERN

Gordon’s functional health patterns is a method devised by Marjory Gordon to

be used in the nursing process to provide a more comprehensive nursing assessment
of the patient. Gordon's functional health patterns provide a holistic model for
assessment of the family because assessment data are classified under 11 headings:
health perception and health management, nutritional-metabolic, elimination, activity
and exercise, sleep and rest, cognition and perception, self-perception and self-
concept, roles and relationships, sexuality and reproduction, coping and stress
tolerance, and values and beliefs.
Date assessed: March 10, 2023
Time: 2:00 pm

1. Health Perception- Health Management Pattern

When it comes to health practices, Patient P frequently self-medicates and

relies on over-the-counter medications and natural remedies for acute ailments like
fever, cough, and colds. The most common medicine she used to treat fever is
Paracetamol. Patient P often gets check and has two doctors that specializes in
Cardiology for her Enlarged Heart and Neurology for her Dizziness. She also has
High Blood Pressure that’s why she was prescribes to have a maintenance
medicine intended for it.

Patient P’s family told us that going to the hospital was never their first
option, instead they brought her to a Faith Healer as the daughter verbalized
“Before namo gi dala si Mama diri ni adto sa jud me sa manambalay kay mga
tinuohan lagi unya gipa tanaw sa namo didto ang condition ni mama kay nakulbaan
me kay lahi man iyang gibati adto na time.” But considering Patient P’s age and
underlying medical condition they decide to bring her to the hospital to check if it
was related to her past problems. After current hospitalization Patient P verbalized
that “If naa koy bation nga dili maayo karun mo diretso nalang jud ko ug pa checkup
sa Doctor para ma agapan ug dili na mo lala ang akong sakit.”

2. Nutritional- Metabolic Pattern

Patient P stands 5’2 and weighs around 60kg and has a body mass index of
24.2 which is classified as normal weight according to the World Health Organization
(WHO). Prior to hospitalization, Patient P is not a picky eater, but she does consume
things that high in sodium. Patient P finds it hard to distinguish whether the food
is too salty or not as her daughter verbalized “Na kusog kaayo na mo kaog parat
si Mama matingala me parat na kaayo ang pagkaon unya mo ana siya nga sakto
radaw. Hilig sab sha mo kaon ug bulad ug mo sawsaw sa patis.” Patient P finds
it difficult to distinguish its taste because for her its taste is just fit for her taste
buds. Patient P doesn’t consume water that is needed by Our body as she
verbalized, “Sa isa ka adlaw isa or duha ra ka baso akong mahurot ug ginagmay
rajud akong inimnan di mansab ko batiog kauhaw.”
Upon admission, there are changes in her diet since she eats food that is served
by the hospital and drinks water more often. She Follow Full diet as advised by the
Doctor and was vigilant towards the food she intakes.

3. Elimination Pattern

Before hospitalization, Patient P stated that she has no problem urinating and
defecating stating, “okay raman akong pag libang og ihi wala koy nakita nga
problema.” She claimed she doesn’t need any assistance when going to the bathroom.
She usually urinates 4-5 times a day and defecates once a day. She also said that she
has no history of having urinary tract infections. During Hospitalization patient P was
advised to wear diapers for her to just stay in bed while urinating to prevent dizziness
and fall. Additionally, when the student nurses asked for the observation of her urine
and stool, she stated that her urine was yellow in color and had no foul odor, and for
the observation of her stool, she said that it was not watery or loose.

4. Activity Exercise Pattern

Prior to hospitalization, she lives an active lifestyle. Her activities of daily living
includes cleaning the house, doing the laundry, cooking, running an errands, buying
supplies for her sari-sari store, and etc., stating “Anad najud ko mag lihok sukad
sauna pa dili sab ko anad magpa tabng kay kaya paman nako ug ako ra” But she was
advised by her children to just stay at home and prevent activities that would cause
her to feel dizzy. Furthermore, she has problems with regards to breathing and her
daily chores serves as her exercise. During hospitalization, she verbalized, “karon
nga dia ko sa hospital sge rajud kog ga higda maong mas mabati nako akong sakit
kay wakoy mabuhat dri, mag sige rakog katulog”. Furthermore, as observed that she
in in her bed having complete rest also as advised by her Physician

5. Sleep- Rest Pattern

Patient P usually sleeps at 12 am because she is fond of using her phone. Her
daughter would remind her to sleep on time, but she would refuse to sleep since she
stated “Dugay ko maka tulog kay ma lingaw ko ug dula sa games sakong cellphone.”
But there are times she sleeps on time. Patient P wakes up early to open her store
and do chores because she was used on doing it.
When asked about her sleeping pattern during confinement, she stated that she
had no problem because she tends to sleep a lot during her stay in the hospital as she
verbalized “Gina bawi jud nako akong tulog Ma’am para mas dali ko maayo.” Patient
P can sleep comfortably during her admission.

6. Cognitive Perceptual Pattern

Patient P is oriented to time, place, and circumstances and she was able to
respond appropriately to the questions given. During the interview, there was no
evidence of difficulty in forming sentences. Patient P finds it difficult to hear
sometimes when the voice is not that loud as she verbalized “Usahay di
nakaayo ko maka dungog medjo naa nakoy pagka bungol gamay maong
patudahan nalang nako ang tingog sakong ka storya para magka
sinabtanay me.” She appears to show no signs of long- term memory loss through
a past health history and was able to recall and elaborate events from the past.
However, there are times where she forget things that just happened recently, stating
“dala saakong edad usahay maka limot ko kung nainom na ba nako akong tambal or
kung asa nako nabutang ang isa ka butang”. Furthermore, Patient P was able to
identify what she ate today and what we had talk about awhile ago. Moreover, when
asked about her vision she claimed that her eyes are somewhat blurry and had an
eye check-up and was prescribed to wear glasses for reading. She claimed that “Maka
kita paman ko Ma’am pero usahay ug gagmay nga mga letters mag lisod nako if di ko
mag suot ug glasses.”

7. Self – Perception – Self – Concept Pattern

Patient P sees herself as a strong and a loving mother to her kids. She is a
loving Wife, and caring Grand Mother to her grandchildren. She is never giving up in
every battle and find independence in doing chores without the help of anyone. She
like to give comfort and is shows courage’s despite her illness. She is willing to do
everything to regain her health back so that she can do the activities she was used to
doing before.

8. Role Relationship Pattern

Patient P is a housewife, but has sari-sari store in their home. She lives with
her husband, two daughters and grandchildren. Her children cover all of her
expenses, such as food, medication, and other necessities. Furthermore, she said that
she has a healthy relationship with anyone she’s fond of taking good care of her
grandchildren and she loves them so much. She also has a healthy relationship with
the people living near them such as their neighbors. She is not conflicted with anyone
and was never fond of chaos.
9. Sexuality Pattern

Patient P is a 69-year-old a mother of 5 children. Due to old age and numerous

illnesses, she is not sexually active anymore. Patient P is married and has children,
and was not ask about sexual lifestyle for the Patients privacy as well.

10. Coping - Stress Tolerance Pattern

Patient P copes with stress by talking to someone and by voicing out her
sentiments. She also copes by praying and by asking for Guidance. She bonds with
her family and would always have a greater outlook in life. Patient P refuses to focus
on the negative side and will always see positivity in every problem.

11. Value Belief Pattern

Patient P is a Protestant by faith. She doesn’t go to church often and just pray
or attend masses by listening to her radio at home or watching mass in the internet of
their television. Despite not going to church she never forgets to pray and ask for
guidance and healing and would always dwell to the Lord.
DEVELOPMENTAL STAGE
(ERIK ERIKSON'S 8 STAGES OF PSYCHOSOCIAL DEVELOPMENT)

Erik Erikson's developmental theory posits 8 sequential stages of individual

human development that are influenced by biological, psychological, and social factors
throughout the lifespan (Orenstein, 2020). Erikson's theory focused on the socio-
cultural aspect of development through an individual's life. The different stages result
in either a positive or negative impact on an individual's relationship with others.
According to Erik Erikson's theory of Psychosocial development, Patient P
belongs to the stage known as Ego Integrity vs. Despair. This stage of development
happens between 65 years of age and above or death. Patient P belongs to the
Integrity because we grow older and become senior citizens, we tend to slow down
our productivity and explore life as a retired person. Erik Erikson believed if we see
our lives as unproductive, feel guilty about our past, or feel that we did not accomplish
our life goals, we become dissatisfied with life and develop despair, often leading to
depression and hopelessness. In the case of Patient P, she states she has been
successful in this stage which leads her to the virtue of wisdom. Wisdom enables an
individual to look back on their life with a sense of closure and completeness, and also
accept death without fear. She has accumulated assurance of its capacity for order
and meaning. Patient P is taking responsibility for her health and is honest about her
emotions. Furthermore, through Integrity, she developed a sense of being a part of the
bigger picture. She has successfully achieved this stage wherein she became
successful in many aspects and is proud of the accomplishments she has in her life
despite the circumstances.
PHYSICAL ASSESSMENT

Physical Assessment is an organized, systemic process of collecting objective data based on health history and head-to-toe examination. The
physical assessment is the first step in the nursing process. It provides the foundation of nursing care planning in which the nurse’s observations play
an integral part in the assessment, intervention, and evaluation phases. The physical assessment was conducted last March 10, 2023 when the patient
was on her 4th day of confinement at Manuel J. Santos Hospital, St. Anthony Nursing Unit. The examiner made the best efforts of obtaining as much
information throughout the interview.

Techniques used: Inspection, Palpation, Percussion, Auscultation

Materials used: Stethoscope, Aneroid sphygmomanometer, tape measure, penlight, pulse oximeter, axillary thermometer

General Survey:

Patient P, a 69-year-old woman who appears in her stated chronological stage, her body type is Ectomorph and her overall appearance was
neat, dressed appropriately, clean and well-groomed. She was pleasant and cooperative during the assessment. The patient stands 5’2 feet, weighs
60 kg and has a body mass index of 24.3 which is classified as normal weight according to the World Health Organization (WHO).

On the day of assessment, March 10, 2023, patient was received lying on bed, alert, awake and coherent with IVF; site dry and intact without
swelling noted. The overall appearance was neat, dressed appropriately, clean and well-groomed. She was pleasant and cooperative during the
assessment. She speaks softly and was able to follow the flow of the conversation with ease.

Time Body Temperature Pulse Rate Respiratory Rate Blood Pressure Oxygen Saturation
11: 00 am 36.4 °C 99 bpm 20 cpm 110/80 mmHg 96 %
1: 30 pm 35.9 °C 92 bpm 20 cpm 100/70 mmHg 98 %

Below is a table that outlines the results of the head-to-toe assessment. Legend:
• Black – Normal findings
• Red – Abnormal findings
Area 1: 30 pm
Inspection:
- Brown skin complexion and uniform in color
Skin - No lesions noted
Palpation:
- Skin is warm to touch with good turgor <3 seconds
Inspection:
- Hair color is black, smooth and silky and evenly distributed all over the scalp
- Scalp is lighter in color than the complexion
- Free from lice, nits, and dandruff
- No scaling and lesions noted
Scalp and Hair Palpation:
- No tenderness or masses noted
-Gray and white haired, showing characteristics of age, smooth and silky and evenly distributed all over the scalp
- Scalp is lighter in color than the complexion
- Free from lice, nits, and dandruff
- No scaling and lesions noted
Inspection:
- Generally round, smooth and firm with prominences in the frontal and occipital area.
- No cephalic deviation was observed
Head
- Palpebral fissure is equal in both eyes
Palpation:
- No presence of nodules, tenderness and masses noted
Inspection:
- Eyebrows are evenly distributed and symmetrically aligned; equal movement
- Eyelashes are equally distributed and curled outward
- Eyelids skin intact, no discharge, no discoloration and lids close symmetrically
- Sclera appears white and free of any lesions
- Pale appearance of the palpebral conjunctiva
Eyes and
- Pupils are equal, round, reactive to light and accommodation (PERRLA)
Visual
- Both eyes are coordinated, move in unison and with parallel alignment
Acuity
- No nystagmus and any shift in fixation were noted
- Patient reports she has blurry vision
- Patient wears reading glasses
Palpation:
- No masses and tenderness noted over the
lacrimal and nasolacrimal gland
Inspection:
- The auricles were aligned with outer canthus
of each eye
Ears
- Pinna is aligned with the outer canthus
- Normal voice tone is audible for the patient; does not have to request the student nurse to repeat words or statements
Palpation:
- The auricles were firm and pinna recoils
after being folded within 2 seconds without pain noted
- Auricles are mobile, firm
- No areas of tenderness on the auricles and mastoid process noted
Inspection:
- Skin color is the same in color as in the
complexion
- No lesions, discharges or flaring noted
Nose
- Both nares are patent
- Nasal mucosa is pinkish in color
Palpation:
- No tenderness of the paranasal sinuses noted
Inspection:
- Dental caries noted on left lower 1st molar
- Buccal mucosa appears pinkish in color
- No gum bleeding
- Tongue is centrally positioned, moist, no whitish coats noted
Mouth and
- Able to move the tongue freely and with strength
Oropharynx
- No nodules, lumps and excoriated areas noted
Palpation:
- No masses or nodules were felt upon moving
her tongue
- No reddened or edematous area noted
Inspection:
- Trachea is in midline position
Neck
Palpation:
- No visible or palpable lumps or masses upon palpation
Inspection:
- Asymmetrical chest expansion view
- Showing signs of dyspnea
Thorax and Palpation:
Lungs - Symmetric thorax expansion
Auscultation:
- Rales heard over the lung bases breath sounds noted
- Diminished breath sounds were noted
Palpation:
- Apical pulsation can be felt on palpation
Heart - Bounding pulsations were noted
Auscultation:
- Gallop sound was noted
Inspection:
Breast - Breasts were even with the chest wall, smooth, and bilaterally round just like the areola.
- Nipples were everted and smooth with no discharges.
Palpation:
- No lumps, bumps, masses and tenderness
noted.
Inspection:
- Capillary refill was <2 seconds on both sides
Upper
- No muscle atrophy noted
Extremities
Palpation:
- Pulsations were full and symmetric in volume on both sides
Inspection:
- Unblemished skin and uniform in color
- No rashes, lesions, discoloration
- The aorta is midline without bruit or visible pulsation
- Abdominal distention were noted (36.5 inches)
Abdomen Auscultation:
-Bowel sounds are high-pitched, gurgling noises that occur approximately every 5 – 15 seconds
Percussion:
- Tympani tic dull abdomen over the stomach, epigastric area
Palpation:
- Superficial & deep palpation without organomegaly or masses; no direct or rebound tenderness
Inspection:
- No asymmetry or muscle atrophy
- Full range of motion (ROM) of all joints
Lower - No edema, or superficial varicosities noted
Extremities - Inguinal lymph nodes not enlarged
Palpation:
- Normal skin temperature
- All distal pulses (or: femoral, popliteal, PT, and DP pulses) intact, full, and equal; no bruits over femoral artery
Inspection:
Musculoskeletal - Symmetric muscles on both side
- No contractures noted
Reproductive The client refused to do the examination.
ANATOMY AND PHYSIOLOGY

Cardiovascular System
Heart and Blood Vessels
The circulatory system is also called the cardiovascular system, where “cardi”
refers to the heart, and “vascular” refers to the blood vessels. So, these are the two
key parts: the heart, which pumps blood, and the blood vessels, which carry blood to
the body and return it back to the heart again. Ultimately, this is how nutrients like O2,
or oxygen, get pushed out to the organs and tissues that need it, and how waste like
CO2, or carbon dioxide, which is the main byproduct of cellular respiration, gets
removed. The heart is about the size of a person’s fist, which makes sense: a bigger
person has a bigger fist and, therefore, a bigger heart. And it’s shaped like a cone,
and sits slightly shifted over to the left side, in the mediastinum, which is the middle of
the chest cavity, or thorax. It sits on top of the diaphragm, which is the main muscle
that helps with breathing, behind the sternum, or breastbone, in front of the vertebral
column, squished in between the two lungs, and protected by the ribs.

If you look more closely, you can see that the heart sits inside a sac of fluid that
has two walls, called the serous pericardium. The outer layer is called the parietal
layer. It gets stuck tightly to another layer called the fibrous pericardium, which is made
of tough, dense connective tissue, which holds the heart in place and prevents it from
overfilling with blood. The inner layer is called the visceral layer, and it gets stuck tightly
to the heart itself, forming the epicardium, or the outer layer of the heart. The cells of
the serous pericardium, both the parietal and visceral layer -- secrete a protein-rich
fluid that fills the space between those layers and serves as a lubricant for the heart,
allowing it to move around a bit with each heartbeat without feeling too much friction.
So, moving from the outside to the inside of the heart, after the epicardium,
there’s the myocardium, which is the muscular middle layer. This forms the bulk of the
heart tissue because those cardiac muscle cells contract and pump blood. In addition
to cardiac muscle cells, there are crisscrossing connective tissue fibers, which are
made of collagen, that together form the fibrous cardiac skeleton, which helps supports
the muscle tissue. The myocardium also has dedicated blood vessels - called coronary
vessels - which lay on the outside of the heart and then penetrate into the myocardium
to bring blood to that layer because it needs a lot of energy to pump blood. Finally,
there’s the innermost layer of the heart, called the endocardium, which is made of a
relatively thin layer of endothelium, which is the same layer of cells that line the blood
vessels. This endocardium lines the heart chambers and heart valves.
All right, so on the right side of the heart, deoxygenated blood enters either
through the top, through a blood vessel called the superior vena cava, or the bottom,
through another blood vessel called the inferior vena cava, in the right atrium, where
“atrium” means “entryway.” Both vena cavas are veins, which bring blood towards the
heart. There’s also a tiny third opening into the right atrium called the coronary sinus,
which collects blood from coronary vessels returning from the myocardium. Now, all
of that blood then goes through the first of two atrioventricular valves that separate the
atria from the ventricles. This one is called the tricuspid valve, and it allows blood into
the right ventricle. The tricuspid valve has three little flaps or ‘cusps’, and each cusp
has tiny little strings called chordae tendinae coming off of it that tether the cusp to a
small muscle called a papillary muscle. When the heart contracts, that papillary muscle
keeps the chordae tendinae taut, and both of these helps to prevent regurgitation of
blood back into the atrium, allowing it to only flow out next valve.

That being said, that contraction pumps the blood out the pulmonary valve
which like the tricuspid valve has three cusps and also prevents blood from going
backwards - but unlike the tricuspid valve, the pulmonary valve doesn’t have any of
those chordae tendinae. Once it’s past the pulmonary valve, the blood goes into the
pulmonary arteries which carry the blood away from the heart to the left and right lung.
The blood goes from the pulmonary artery into a pulmonary arteriole, which is a bit
smaller, and finally into a capillary, which is the smallest. In the lungs, the capillary
lines up alongside a small sack of air called an alveolus - and when you have a lot of
them, they’re called alveoli. Up until now the blood has been loaded with carbon
dioxide, which makes the blood look dark red rather than blue, which is how it’s usually
drawn, and how we’ll still draw it to stay consistent. Now, at this point in the journey,
the carbon dioxide moves from the capillary to the alveolus and oxygen moves from
the alveolus to the capillary, giving the blood that nice bright red color.
Now, in the blood, each red blood cell has millions of hemoglobin proteins, and
each of this hemoglobin can bind to four oxygen molecules, so each red blood cell can
carry millions of oxygen molecules when fully loaded! The oxygen-rich blood moves
into a venule and then eventually into a pulmonary vein that dumps the blood into the
left atrium. This trip -- from the right ventricle of the heart through the pulmonary artery
to the lungs and back to the left atrium of the heart -- is called the pulmonary
circulation. After entering the left atrium, the blood goes through the second
atrioventricular valve, called the mitral valve, into the left ventricle. The mitral valve
has only two cusps or leaflets, one in front called the anterior leaflet that’s a little
smaller and one behind it called the posterior leaflet. Both of these have chordae
tendinae coming off of them that tether the valve to papillary muscles in the left
ventricle. Similar to the right side of the heart, when it contracts, this prevents blood
from going backwards.

Finally, blood in the left ventricle gets pumped out through the aortic valve,
which normally has three cusps, out to the aorta, the largest artery in the body. Just
like in the lungs, the aorta branches into arterioles which are smaller arteries and finally
into capillaries which are the smallest, and at that point they’re at the organs and
tissues. In the organs, the red blood cells line up alongside tissue cells and drop off
oxygen and pick up carbon dioxide, basically the reverse of what happened with the
alveolus in the lung. Loaded up with carbon dioxide, the blood turns that dark red color
again, shown as blue, and starts the return journey to the heart by going into small
venules and then larger veins. Now, the lower half of the body drains into the inferior
vena cava, and the upper half drains into the superior vena cava, both of which dump
blood back into the right atrium. So, this trip -- from the left ventricle of the heart to the
body and back to the right atrium of the heart -- is called the systemic circulation. Now,
relative to the pulmonary circulation, the systemic has a lot more blood vessels, which
means there’s about a 5 times greater resistance to blood flow, which essentially
meaning it’s a lot harder to pump blood through, even though it’s the same amount of
blood being pumped as the pulmonary side. Because of this difference, the left
ventricle needs to be stronger, and so the muscular layer of the left ventricle wall - or
its myocardium - is three times thicker than the right ventricle’s myocardium.
Cardiac Circulation Vessels
Coronary arteries. The coronary arteries branch from the base of the aorta and
encircle the heart in the coronary sulcus (atrioventricular groove) at the junction of the
atria and ventricles, and these arteries are compressed when the ventricles are
contracting and fill when the heart is relaxed.
Cardiac veins. The myocardium is drained by several cardiac veins, which
empty into an enlarged vessel on the posterior of the heart called the coronary sinus.
Arterial Branches of the Ascending Aorta
The aorta springs upward from the left ventricle of heart as the ascending aorta.
Coronary arteries. The only branches of the ascending aorta are the right and left
coronary arteries, which serve the heart.
Tunica intima. The tunica intima, which lines the lumen, or interior, of the vessels, is
a thin layer of endothelium resting on a basement membrane and decreases friction
as blood flows through the vessel lumen.
Tunica media. The tunica media is the bulky middle coat which mostly consists of
smooth muscle and elastic fibers that constrict or dilate, making the blood pressure
increase or decrease.
Tunica externa. The tunica externa is the outermost tunic composed largely of fibrous
connective tissue, and its function is basically to support and protect the vessels.

Symptoms of heart disease in the blood vessels

Coronary artery disease is a common heart condition that affects the major
blood vessels that supply the heart muscle. Cholesterol deposits (plaques) in the heart
arteries are usually the cause of coronary artery disease. The buildup of these plaques
is called atherosclerosis (ath-ur-o-skluh-ROE-sis). Atherosclerosis reduces blood flow
to the heart and other parts of the body. It can lead to a heart attack, chest pain
(angina) or stroke.
Coronary artery disease symptoms may be different for men and women. For
instance, men are more likely to have chest pain. Women are more likely to have other
symptoms along with chest discomfort, such as shortness of breath, nausea and
extreme fatigue.
Symptoms of coronary artery disease can
include:
Chest pain, chest tightness, chest pressure
and chest discomfort (angina)
Shortness of breath
Pain in the neck, jaw, throat, upper belly
area or back
Pain, numbness, weakness or coldness in
the legs or arms if the blood vessels in those body areas are narrowed
Such conditions like coronary artery disease and cardiomyopathy can lead to
damage of the heart muscle. Regardless, all of these conditions can reduce the heart's
ability to pump blood efficiently and consequently cause the heart muscle to enlarge,
resulting in cardiomegaly.
Cardiomegaly - Heart enlargement can be your heart’s reaction to something
that forces it to use more effort to circulate blood.
NERVOUS SYSTEM
The brain, spinal cord, and nerves make up the nervous system. It greatly
controls how human feels and thinks, as well as how their bodies behave. It allows
also to do things like walk, speak, swallow, breathe and learn.
The nervous system
is mainly made up of cells
called neurons. These are
responsible for carrying
messages to and from
different parts of the body.
Neurons are connected to
each other, and to other
cells, by synapses, which
carry electrical signals, and
neurotransmitters, which are
the body’s chemical
messengers.

Your brain is an
essential organ that controls many body functions. Your brain receives and interprets
all the sensory information you encounter, like sights, sounds, smells and tastes. Your
brain has many complex parts that work together to help you function.
What is the brain’s function?
Your brain receives information from your five senses: sight, smell, sound,
touch and taste. Your brain also receives inputs including touch, vibration, pain and
temperature from the rest of your body as well as autonomic (involuntary) inputs from
your organs. It interprets this information so you can understand and associate
meaning with what goes on around you.
Your brain enables:
• Thoughts and decisions.
• Memories and emotions.
• Movements (motor function), balance and coordination.
• Perception of various sensations including pain.
• Automatic behavior such as breathing, heart rate, sleep and temperature
control.
• Regulation of organ function.
• Speech and language functions.
• Fight or flight response (stress response).

What are the lobes that make up your brain?

Each side of your brain has different lobes (sections). While all the lobes work
together to ensure normal functioning, each lobe plays an important role in some
specific brain and body functions:
Frontal lobes: The frontal lobes are in the front part of your brain, right behind your
forehead. This is the largest lobe and it controls voluntary movement, speech and
intellect. The parts of your frontal lobes that control movement are called the primary
motor cortex or precentral gyrus. The parts of your brain that play an important role in
memory, intelligence and personality include your prefrontal cortex as well as many
other regions of your brain.
Occipital lobes: These lobes in the back of your brain allow you to notice and interpret
visual information. Your occipital lobes control how you process shapes, colors and
movement.
Parietal lobes: The parietal lobes are near the center of your brain. They receive and
interpret signals from other parts of your brain. This part of your brain integrates many
sensory inputs so that you can understand your environment and the state of your
body. This part of your brain helps give meaning to what's going on in your
environment.
Temporal lobes: These parts of the brain are near your ears on each side of your
brain. The temporal lobes are important in being able to recall words or places that
you've been. It also helps you recognize people, understand language and interpret
other people’s emotions.

The central nervous system (CNS) is composed of the brain and spinal cord.
The peripheral nervous system (PNS) is composed of spinal nerves that branch from
the spinal cord and cranial nerves that branch from the brain.
Cerebrum: is the largest part of the brain and is composed of right and left
hemispheres. It performs higher functions like interpreting touch, vision and hearing,
as well as speech, reasoning, emotions, learning, and fine control of movement.
Cerebellum: is located under the cerebrum. Its function is to coordinate muscle
movements, maintain posture, and balance.
Brainstem: acts as a relay center connecting the cerebrum and cerebellum to the
spinal cord. It performs many automatic functions such as breathing, heart rate, body
temperature, wake and sleep cycles, digestion, sneezing, coughing, vomiting, and
swallowing.

Right brain – Left brain hemispheres

The cerebrum is divided into two halves: the right and left hemispheres (Fig. 2)
They are joined by a bundle of fibers called the corpus callosum that transmits
messages from one side to the other. Each hemisphere controls the opposite side of
the body. If a stroke occurs on the right side of the brain, the left arm or leg may be
weak or paralyzed. Not all functions of the hemispheres are shared. In general, the
left hemisphere controls speech, comprehension, arithmetic, and writing. The right
hemisphere controls creativity, spatial ability, artistic, and musical skills. The left
hemisphere is dominant in hand use and language in about 92% of people.
Blood Flow to the Brain
The heart pumps blood up to the brain through two sets of arteries, the carotid
arteries and the vertebral arteries. The carotid arteries are located in the front of the
neck and are what you feel when you take your pulse just under your jaw. The carotid
arteries split into the external and internal arteries near the top of the neck with the
external carotid arteries supplying blood to the face and the internal carotid arteries
going into the skull. Inside the skull, the internal carotid arteries branch into two large
arteries – the anterior cerebral and middle cerebral arteries and several smaller
arteries – the ophthalmic, posterior communicating and anterior choroidal arteries.
These arteries supply blood to the front two-thirds of the brain.
The vertebral arteries extend along-side the spinal column and cannot be felt
from the outside. The vertebral arteries join to form a single basilar artery near the
brain stem, which is located near the base of the skull. The vertebrobasilar system
sends many small branches into the brain stem and branches off to form the posterior
cerebellar and posterior meningeal arteries, which supply the back third of the brain.
The jugular and other veins carry blood out of the brain.
At the base of the brain, the carotid arteries and vertebral arteries come
together to form the Circle of Willis. This is a circle of arteries that provide many paths
for blood to supply oxygen and nutrients the brain.

From the Circle of Willis, major arteries arise and travel to all parts of the brain.
Some common blood vessels in the Circle of Willis that are affected by stroke are:
Anterior Cerebral Artery (ACA): This vessel supplies blood to the front part of the
brain, knows as the frontal lobe. There is a right sided ACA and a left sided ACA. If a
stroke occurs in this area, one may see leg weakness and/or difficulty thinking and
making decisions. There could also be changes in personality.
Middle Cerebral Artery (MCA): This vessel supplies blood to the middle part of the
brain. There is a right sided MCA and a left sided MCA. These blood vessels are the
most commonly affected in a stroke. If a stroke occurs in this area, one may see:
• Paralysis on one side of the body
• Changes in sensation
• Blindness (either on the left or right side)
• Language problems, such as difficulty with forming words and sentences or
difficulty with understanding what others are saying
Posterior Cerebral Arteries (PCA): These vessels supply blood to the back of the
brain. There is a right sided PCA and a left sided PCA. If a stroke occurs in this area,
one may notice problems with vision.
Thalamus: The thalamus is a small structure within the brain located just above the
brain stem between the cerebral cortex and the midbrain and has extensive nerve
connections to both. The primary function of the thalamus is to relay motor and sensory
signals to the cerebral cortex. It also regulates sleep, alertness, and wakefulness.
Thalamic Arterial Blood Supply: The primary blood supply of the thalamus is from
the posterior cerebral artery. Contributing branches from the posterior communicating
artery also supply the thalamus after passing through the posterior perforated
substance.
Thalamic Venous Drainage: Deep cerebral veins such as the thalamostriate and
lateral thalamic veins drain the thalamus. These drain into internal cerebral veins and
the basal vein of Rosenthal and subsequently join the great vein of Galen except
invariant cases. It is important to note that venous infarctions and neoplasms have
variable clinical presentations because they do not affect individual arterial territories.
Because the brain relies on only two sets of major arteries for its blood supply, it is
very important that these arteries are healthy. During a hemorrhagic stroke, an artery
in or on the surface of the brain has ruptured or leaks, causing bleeding and damage
in or around the brain.
Whatever the underlying condition and cause are, it is crucial that proper blood flow
and oxygen be restored to the brain as soon as possible. Without oxygen and
important nutrients, the affected brain cells are either damaged or die within a few
minutes. Once brain cells die, they cannot regenerate, and devastating damage may
occur, sometimes resulting in physical, cognitive and mental disabilities.
These are the conditions or disorders that affects the brain:
About 1 in 6 people have some type of brain condition. There are many types
of brain disorders and conditions that vary in severity, including:
Alzheimer’s disease and dementia: Progressive loss of cognitive (brain) functions,
such as memory, problem-solving or language.
Amyotrophic lateral sclerosis (ALS): A neuromuscular disorder where the nerve
cells in your brain break down.
Autism spectrum disorder (ASD): A developmental disorder that can affect your
ability to communicate, regulate behavior or interpret social cues.
Brain tumor: Irregular mass of cells that starts in your brain and grows uncontrollably.
Epilepsy: A brain disorder that disrupts the activity of your brain’s nerve cells, leading
to seizures.
Parkinson’s disease: A progressive nervous system disease that often starts with
tremors (uncontrollable shakes).
Stroke: An interruption of blood supply to your brain, either because of an artery
blockage or artery rupture (burst).
PATHOPHYSIOLOGY
LABORATORY RESULTS

Red Values Indicates Abnormalities.

Green Values Indicate Normal.

LABORATORY RESULTS NO. 1

Date Collected: 3/7/2023 – 10:00 AM

Date Released: 3/7/2023 – 11:07 AM

CLINICAL CHEMISTRY

LIPID PROFILE

TEST RESULT UNIT REFERENCE RANGE INTERPRETATION

Cholesterol 185.00 Mg/dL < 200 Normal Range
Triglyceride 53.00 Mg/dL < 200 Normal Range
HDL/High Density >60 Mg/dL (Low Risk)
Lipoprotein 62.00 Mg/dL 35-60 Mg/dL (Normal Risk) Normal Range
<35 Mg/dL (High Risk)
LDL / Low Density < 130
112.40 Mg/dL Normal Range
Lipoprotein

LABORATORY RESULTS NO. 2

Date Collected: 3/8/2023 – 11:00 AM

Date Released: 3/8/2023 – 12:51 PM

CLINICAL CHEMIST NO. 2

PROTHROMBIN INR

TEST RESULT REFERENCE RANGE INTERPRETATION

0.80-1.20 = (Normal)
2.0-3.0 = (Anticoagulated Patient)
2.5-3.5 = (Patient Treated for Recurrent
1.01 NORMAL
Embolism or have Mechanical Prosthetic
Heart Valves
Above 4.9 = Critical Value
LABORATORY RESULTS NO. 3

Date Collected: 3/9/2023 – 8:10 PM

Date Released: 3/9/2023 – 9:34 PM

CLINICAL CHEMIST NO. 3

ELECTROLYTE PANEL

TEST
REFERENCE
ELECTROLYTE RESULT UNIT INTERPRETATION
RANGE
PANEL
Function of Potassium
Relaxes the Blood Vessels
so that Blood Flows
through them more easily,
with less pressure. With
Low Potassium, Blood
Vessels are constricted
Potassium 3.1 Mmol/L 3.5-5.3
blocking the Blood Vessels
and having more pressure
of the blood to flow
properly as well as Body
Malaise, Cramps,
Twitching, Tachycardia,
Paralysis or Coma.
Sodium 141 Mmol/L 135-148 Normal Range
DRUG STUDY

NAME OF DOSAGE/ MECHANISM OF ADVERSE NURSING

CLASSIFICATION INDICATION CONTRAINDICATION
DRUG PREPARATION ACTION EFFECT RESPONSIBILITY
• Swelling of the
hands, feet,
It works by relaxing ankles, or
5 mg lower legs.
your blood vessels to Contraindicated in
Report any rhythm
lower your blood patients with • Headache
Color orange disturbances or symptoms
pressure. This also cardiogenic shock, • Upset stomach
Amlodipine of increased arrhythmias,
Calcium channel helps your heart to get Treat high blood severe aortic stenosis, • Nausea
(Norvasc) Frequent 1-tab OD including palpitations, chest
blocker
(one a day)
more oxygen so it pressure unstable angina, severe • Stomach pain pain, and shortness of
doesn't need to work hypotension, heart dizziness or breath, fainting, and
as hard to pump, which failure, and hepatic lightheadedne
Timing 8 AM fatigue/weakness.
can help with chest impairment. ss
pain. • drowsiness
excessive
tiredness.
• Instruct patient to take
the medication as
prescribed.
Cerebrovascular
4g IV Q12H • Teach the patient that
Diseases (eg, from
Increases cerebral citicoline may be taken
Ischemia due to Stomach pain,
Color Light Pink metabolism and the Hypersensitivity with with or without food.
Stroke): Citicoline back pain, blurred
Citicoline
Psychostimulant
level of various
accelerates the
Patients with hypertonic
vision, • Monitor for adverse
(Zynapse) Frequent Q12H neurotransmitters, of the parasympathetic. effects; instruct patient
recovery of constipation, and
(Every 12 hours) including acetylcholine to report immediately if
consciousness and headache.
and dopamine. he/she develops chest
overcoming motor
Timing 8AM – 8PM tightness, tingling in
deficit.
mouth and throat,
headache, diarrhea and
blurring of vision.
• Bleeding gums
2.5mL 1tab run for
4hours It is indicated in • Nosebleeds
It works by decreasing • Red, brown
patients with non- Educate patients about
the clotting ability of the urine
Apixaban Color blue BID valvular atrial signs and symptoms of
blood and helps Severe hypersensitivity
(Eliquis) Anticoagulant (Twice a day) fibrillation to reduce • Red or black, bleeding and bleeding
preventing harmful to the drug
the risk of stroke tarry stools. precautions
clots from forming in
Timing 8 AM &
the blood vessels.
and systemic • Swelling or
12NN embolism. joint pain
• Headache
• Nausea
Ménière's Syndrome as
Betahistine affects the defined by the following • Dyspepsia
• Headache • Advice to take this
histaminergic system, acts both triad of core symptoms: Hypersensitivit
• Vomiting drug should be
as a partial histamine H1- vertigo (with y to the active
Serc Class of 24 ml 1 TAB taken with food.
receptor agonist and histamine nausea/vomiting); hearing substance or • Gastrointestinal
(Betahistine) antivertigo TID
H3-receptor antagonist also in loss (hardness of hearing); to any of the pain • Protect medication
neuronal tissue, and has tinnitus. excipients. from moisture
• Abdominal
negligible H2-receptor activity. . Symptomatic treatment of distension
vestibular vertigo.
• Bloating
Maintenance therapy for
symptoms of
Cinnarizine is a selective • Somnolence
cerebrovascular origin
calcium-entry blocker belonging
(including dizziness, ear • GI disturbances Instruct patient to take
Stugeron Class of 75 mg 1 CAP to group IV of the calcium Hypersensitivit
buzzing, vascular • Nausea the medication as
(Cinnarizine) antivertigo OD antagonists (WHO classification). y.
It has an antihistamine (H1)-
headache, unsociability & • Headache prescribed.
effect (Stugeron Forte).
irritability disorders, loss of • Dry mouth
memory & lack of
concentration).
The potassium ion is the principal • Arrange for serial
Nausea, vomiting,
intracellular cation of most body serum potassium
diarrhoea and
tissues. It in a number of
bleeding of the levels before and
essential physiological processes Hypersensitivit
digestive tract, during therapy.
including the maintenance of Potassium chloride is used y to any
Kaligen
Class of
1 TAB TID intracellular tonicity, the to prevent or to treat low component of
uneven heartbeat, • Administer oral
potassium muscle weakness or drug after meals or
transmission of nerve impulses, levels of potassium. the
limp feeling, severe with food and a full
the contraction of cardiac, formulation.
stomach pain and glass of water to
skeletal, and smooth muscle, and
numbness in hands,
the maintenance of normal renal decrease GI upset.
feet or mouth.
function.
40mg 1 TAB OD Inhibits HMG-CoA Atorvastatin is Patients with Abdominal pain, Alert: Monitor
POST SUPPER reductase,an early used together with hypersensitivity to patient closely
( and rate- limiting) a proper diet anyof its diarrhea, during therapy
Generic Name: Color Orange step in cholesterol to lower cholesterol components. because of risk
Atorvastatin biosynthesis and triglyceride dyspepsia, pulmonary infection
Liphophilic (fats) levels in the
Brand Name: Timing blood. This flatulence, Instruct to take
Lipitor 8 AM medicine may help drug with meals;
prevent medical nausea food significantly
Oral: Route problems (eg, enhances
chest pain, heart absorption
attack, or stroke)
that are caused by Advise patient to
fats clogging the report adverse
blood vessel reactions

Generic Name: 2.5mL 1 Educate patients

Apixaban TAB run4hrs BID It's used to treat about signs and
Anticoagulation Inhibits free and people who have symptoms of
Brand name: Color blue BID clot-bound had a health Nausea, easy bleeding and
Eliquis (Twice a day) problem caused by bruising, orminor bleeding
a blood clot, such Severe bleeding (such precautions.
Timing 8 AM & as: a blood clot in hypersensitivity as nosebleed,
12NN the leg (deep vein bleeding from cuts) Instruct patients
thrombosis, or may occur not to double up on
Route : Oral DVT) dosing in an
attemptto make up
a misseddose

monitor the
electrocardiogram
200 mg 1 TAB OD continuously during
Generic Name: IV amiodarone
Amiodarone Color orange It works by slowing It works directly on fatigue, malaise, infusion and
down overactive the heart tissue patients tremor, insomnia, initiation of PO
Brand Name: anti-arrhythmic drug Frequent 1 tab OD electric signals in and will slow the with cardiogenic sleep disturbances therapy.
Nexterone, (one a day) the heart, which nerve impulses in shock, marked , headache, and
Paceron stabilizes your the heart. This sinus bradycardi dizziness.. monitor your
Timing 8 AM heart rhythm helps keep your patient's
heart rhythm respiratory status
Route : oral normal. carefully.
PROBLEM PRIORITIZATION

IDENTIFIED
DATE DATE
PRIORITY NO. NUSING
IDENTIFIED EVALUATED
PROBLEM

Electrolyte
1 Imbalance related 3/10/2023 3/13/2023
Hypokalemia

Risk for fall related

2 to Dizziness and 3/10/2023 3/13/2023
severe headache

Activity Intolerance
3 3/10/2023 3/13/2023
related to Stroke
NURSING CARE PLAN #1

Assessment Diagnosis Outcomes Intervention Rationale Evaluation

Objectives: Electrolyte Short term goal: 1. Monitor for signs and - Hypokalemia can be a life Short term goal:
Imbalance symptoms of hypokalemia: threatening. Careful
BP: 100/70 related Within 8 hours of -Fatigue assessment for its early After 8 hours of
mmHg Hypokalemia nursing -Anorexia presence is needed especially nursing intervention,
T: 35.9 °C intervention, the -muscle weakness for high risk patients. the patient was able to
PR: 92 bpm patient will be able -Increased bowel motility identify individual risks
RR: 20 bpm to identify individual -Dysrhythmias and engage in
O2: 98% risks and engage in -Shallow respirations 2. It will help in formulating appropriate behaviors
appropriate -Weak thread pulse appropriate interventions to the or lifestyle changes to
- Potassium: behaviors or patient. prevent or reduce
3.1 lifestyle changes to 2. Identify client with current frequency of
- muscle prevent or reduce or newly diagnosed condition electrolyte
weakness frequency ofcommonly associated with imbalances.
electrolyte electrolyte imbalances, such 3. To note presence of
imbalances. as inability to eat or drink, anorexia, vomiting, or recent
febrile illness, active bleeding fad or unusual diet; look for
or other signs of chronic malnutrition. Long term goal:
Long term goal: fluid loss, including vomiting,
diarrhea, gastrointestinal 4. Including client in the plan of After 3 days of nursing
Within 3 days of drainage, or burns. care elicits participation. Also, intervention, the
nursing potassium rich foods in the diet patient was able to
intervention, the 3. Review the client’s food help maintain. display laboratory
patient will be able intake. results within normal
to display laboratory 5. Many factors, such as in range for individual.
results within 4. Assist client in selecting ability to drink that may affect
normal range for foods rich in potassium as an individual’s fluid balance,
individual. such as banana, fruit juices, disrupting electrolyte transport,
melon, citrus fruits, and fresh function, and excretion.
vegetables.
6. Electrolytes
5. Assess fluid intake and include sodium, potassium,
output. calcium, chloride, bicarbonate
6. Review laboratory results (carbon dioxide), and
for abnormal findings. magnesium. These chemicals
are essential in many bodily
7. Note presence of medical functions.
conditions that may impact
potassium level. 7. Hypokalemia may include
attacks of severe muscle
8.Educate the patient using weakness, eventually leading
potassium wasting about to paralysis and possibly
potassium replacements. respiratory failure.

9.Monitor I & O and IV fluid. 8. To prevent hypokalemia, the

patient needs to understand
10. Monitor ECG, as the importance of potassium
indicated. replacements that include
dietary sources and prescribed
11. Review client’s oral replacements such as
medications at each visit. potassium chloride.

9. To determine if IV fluid and

electrolyte replacements are
needed.

10. Abnormal potassium levels,

both low and high, are
associated with changes in the
ECG.

11. To reduce potential of

complications associated with
medication-induced electrolyte
imbalances.
NURSING CARE PLAN #2

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective Risk for fall Short term: 1. Obtain the patient’s 1. To determine the
cues: related to Within 4hrs of vital signs abnormal findings and to Short term:
Dizziness and nursing know the current vital Within 2hrs of nursing
“Ang akong severe interventions, the 2.Identify risk factors that signs of the patient. interventions, the
pamati karun headache patient will be able to increases the risk of falling. patient is able to
ma’am kay lipong verbalize 2. It will help in determining verbalize
kaayo ug labad understanding of 3. Thoroughly assess the interventions necessary to understanding of
ang akong ulo” individual risk factors process of factors known decrease the risk of falling. individual risk factors
that contribute to the to increase fall risk such as that contribute to the
Objective Cues: possibility of falls. history of falls, mental 3.Evidences indicates that a possibility of falls.
status changes and person who experienced
-69 years’ old Long term: sensory deficits such as more falls in the past will Patient is able to:
-Hearing loss Within 1 week of blurred vision, usual more likely to fall again and
-Dizziness or nursing feeling of dizziness etc. this will help in formulating 1. Explain her personal
vertigo interventions, the the interventions to the ideas in promoting her
- patient will be able to 4.Thoroughly orient the patient. own safety.
Lightheadedness Demonstrate patient to environment for 4. To be familiar within her 2. Elaborate the risk
-Pale behaviors and factors known to unfamiliar environment. factors of falls.
-Dry skin lifestyle changes to setting and inadequate
-Loss of muscles reduce risk factors lighting. 5. To ensure the clients Long term:
strength and and protect self from safety. Within 1 week of
can’t able to injury. 5. Ask the significant nursing interventions,
stand others to always stay with 6. Stretching to get items the patient was able to
-low potassium the patient from time to from bedside that are out of Demonstrate behaviors
time. reach can disrupt the and lifestyle changes to
Vital Signs: patient’s balance and reduce risk factors and
T: 36.6% 6. Place items used by the contribute to falls. protect self from injury
P:62 bpm patient within easy reach.
R: 21 bpm 7. To reduce the risk of falling Patient is able to:
BP:140/80 7. Used side rails on bed and patient who are
O2Sat: 97% as needed. disoriented or confused have 1. Large consumption
been known to climb over of nutritious foods,
8. Take medications side rails and fall. particularly those high
prescribed by the 8. To help prevent the in potassium such as
physician. problems identified. bananas, avocados,
carrots, and oranges.
9. Encourage the patient to 9. To increase her intake of
eat nutritious foods potassium and it will protect 2. Exercise regularly for
especially high in her against stroke. Evidence about 10-20 minutes
potassium and teach the suggest that people who per day.
patient the importance of engage in regular exercise
maintaining a regular will help strengthen the 3. Use appropriate
exercise. muscles and prevent from slipper
falls.
10. Encourage the patient 4.Demonstrate the use
to have adequate of rest. 10. To support healthy brain of a walker.
function and maintain
11.Ensure the patient to physical health. Inadequate Goal met as evidenced
wear shoes with hard soles sleep overtime can raise the by the verbalization of
and low heels. risk for chronic health the patient “Na okay na
problems. ako paminaw ug kaloy
12. Encourage the patient an sa ginoo wala man
to use assistive devices 11. To prevent from noon ko natumba na”
(e.g., crutches, walker, and slippering
wheelchair)
12. To protect client from
possibility of fall or injury
NURSING CARE PLAN #3

Assessment Diagnosis Outcomes Intervention Rationale Evaluation

Subjective: Activity Short term goal: 1. Assess the physical activity - Provide baseline Short term goal:
Intolerance level and mobility of the patient.information for
“Dili ko kaayo related to Within 6 hours of formulating nursing goals After 6 hours of nursing
makalihok Stroke nursing 2. Assess cardiopulmonary intervention, the patient was
tungod kay ang intervention, the response to physical activity, - Dramatic changes in able to Participate willingly in
ahung lawas patient will be including vital signs, before, heart rate and rhythm, necessary/desired activities.
nagluya pa.” able to during, and after activity. Note changes in usual blood
Participate accelerating in pressure, and
willingly in fatigue. progressively worsening Patient is able to:
Objectives: necessary/desire fatigue result from an
d activities. imbalance of oxygen 1. walk gradually with
BP: 100/70 3. Ascertain ability to stand and supply and demand. assistive device such as
mmHg move about and degree of walker.
T: 35.9 °C Long term goal: assistance necessary or use of - to determine status and
PR: 92 bpm equipment. needs associated with 2. transfer from bed to chair
RR: 20 bpm Within 5 days of participation in needed/ with assistance of SO.
O2: 98% nursing desired activities.
intervention, the 4. Determine the patient’s level 3. maintain unsupported
- pale looking patient will be of activity intolerance. - To provide a baseline for standing balance for 30
and weakness able to Maximize comparison and track seconds.
noted. functional patient’s progress.
abilities and level 5. Establish guidelines and -Goal met.
of independence. goals of activity with both - Motivation and
patient and SO. cooperation are
enhanced if the patient
participates in goal
6. Have the patient perform the setting.
activity more slowly, in a longer
time with more rest or pauses, - to helps in increasing the Long term goal:
or with assistance if necessary tolerance for the activity
- Gradual progression of After 5 days of nursing
7. Gradually increase activity the activity prevents intervention, the patient was
with active range-of-motion overexertion. able to maximize functional
exercises in bed, increasing to abilities and level of
sitting and then standing. - Helps promote a sense independence.
8. Encourage physical activity of autonomy while being
consistent with the patient’s realistic about Patient is able to:
energy levels. capabilities.
1. walk up to the bathroom
9. Encourage verbalization of - Verbalization of feelings and bath himself alone.
feelings regarding limitations. can help the patient to
Provide a positive atmosphere. cope and minimizes 2. safely perform sit to stand
frustration. Acknowledge pivot transfer without
the patient’s feelings assistance.
10. Encourage active ROM about activity intolerance
exercises. Encourage the as this can be both 3. Independently perform
patient to participate in physically and ADLs.
planning activities that emotionally difficult.
gradually build endurance. -Goal met.
- Physical inactive
patients need to improve
11. Teach the patient and/or functional capacity
SO to recognize signs of through repetitive
physical overactivity or exercises over a long
overexertion. period of time. Strength
training is valuable in
enhancing endurance of
many ADL
12. Assist with activities and
provide/monitor client’s use of - Knowledge promotes
assistive devices (e.g., awareness to prevent the
crutches, walker, and complication of
wheelchair) overexertion.

13. Note client reports of - to protect client from

weakness, fatigue, pain, and injury.
difficulty accomplishing tasks.
- Symptoms may be result
of or contribute to
intolerance of activity
DISCHARGE PLAN

Discharge planning is the process of identifying and preparing for a patient's

anticipated health care needs after they leave the hospital According to Myers, et al.
(2004). These includes Medication, Environment and Exercise, Treatment, Health
teachings, Observable signs, Diet, Spiritual which does help the patient with
coordinated care.

MEDICATION
• Continue medication of maintenance drugs and notify physician of adverse
effects.
• Medication intake should be taken completely.
• Advise importance of not missing medication intake prescribed by the doctor.
• Provide contraindications as it may be harmful for the patient.
ENVIRONMENT AND EXERCISE
• Instruct a stress-free environment for the patient.
• Provide a clean environment for the patient by eliminating possible issues of
contamination that may be harmful for the patient.
• Avoid strenuous activities.
• Avoid polluted environment
TREATMENT
• Instruct for the continuation of home medication prescribed by the physician.
• Advise for a follow-up-checkup for the optimal recovery process and tracking
of health status.
• Encourage adequate liquids for the patient for the rehydration of the body.
HEALTH TEACHINGS
• Encourage adequate rest of 6-8 hours daily.
• Have significant others track any symptoms of stroke which will be directly be
treated.
• Encourage to adhere to medications and treatments prescribed by the doctor.
• Encourage therapeutic communication which will help the patient in the
recovery process.
OBSERVABLE SIGNS
• Teach on warning signs of stroke
F – Face one side of the face is drooping
A – Arms or Legs weakness
S – Speech difficulty
T – Time to call for ambulance immediately.
• Low potassium symptoms:
-Alkalosis
-Shallow respiration
-Irritability
-Confusion
-Weakness
-Arrythmias
-Lethargy
-Thready pulse
-Intestinal motility
DIET
• Consume adequate amounts of potassium-rich foods, such as bananas,
potatoes, spinach, broccoli, avocado, watermelon, peas, pumpkins,
mushrooms.
• Avoid too much salt in the diet.
• Intake of high-fiber, high protein and low-fat diet.

SPIRITUAL
• Encourage patient to have guidance and have a daily prayer to have a faith
and to empower the patient to have positive encouragement, guidance of
God, and strengthen relationship with God.
LEARNING OUTCOMES
REFERENCES
GoodRx - Error. (n.d.). https://www.goodrx.com/amlodipine/what-is

R. (2021, June 19). RNspeak. RNspeak | Nursing Journal. https://rnspeak.com/citicoline-

drug-study/

Agrawal, A. (2022, October 11). Apixaban. StatPearls - NCBI Bookshelf.

https://www.ncbi.nlm.nih.gov/books/NBK507910/

Becker, M. L., Elens, L., Visser, L. G., Hofman, A., Uitterlinden, A. G., Van Schaik, R., &

Stricker, B. H. (2013, June 1). Genetic variation in the ABCC2 gene is associated

with dose decreases or switches to other cholesterol-lowering drugs during

simvastatin and atorvastatin therapy. Pharmacogenomics Journal; Nature Portfolio.

https://doi.org/10.1038/tpj.2011.59

Singh, B. N., & Williams, E. M. V. (1970, August 1). The effect of amiodarone, a new anti-

anginal drug, on cardiac muscle. British Journal of Pharmacology; Wiley-Blackwell.

https://doi.org/10.1111/j.1476-5381.1970.tb09891.x

Apixaban (Oral Route) Side Effects - Mayo Clinic. (n.d.). https://www.mayoclinic.org/drugs-

supplements/apixaban-oral-route/side-effects/drg-20060729?p=1

RNspeak. (2018). Serc (Betahistine Dihydrochloride) Drug Study. Rnspeak.com.

https://rnspeak.com/serc-betahistine-dihydrochloride-drug-study/

Kaligen (Potassium Chloride) 750mg Sustained Release Tablet | Online Pharmacy &

Healthcare Store | eHealthPlus. (n.d.). Retrieved March 12, 2023, from

https://ehealthplusph.com/product/kaligen-potassium-chloride-750mg-sustained-

release-tablet/

Erik Erikson's 8 Stages of Psychosocial Development. (2022). Retrieved 15 March 2023,

from https://simplypsychology.org/Erik-Erikson.html
Erik Erikson’s Theory of Psychosocial Development - RNpedia. (2014). Retrieved 15 March

2023, from https://www.rnpedia.com/nursing-notes/psychiatric-nursing-notes/erik-eriksons-

theory-psychosocial-development/

Acute Disseminated Encephalomyelitis. (2023). Retrieved 16 March 2023, from

https://www.ninds.nih.gov/health-information/disorders/acute-disseminated-

encephalomyelitis#:~:text=Acute%20Disseminated%20Encephalomyelitis,of%20Neurologic

al%20Disorders%20and%20Stroke

Mehndiratta, M., Pandey, S., Nayak, R., & Alam, A. (2012). Posterior Circulation Ischemic

Stroke—Clinical Characteristics, Risk Factors, and Subtypes in a North Indian Population.

The Neurohospitalist, 2(2), 46-50. doi: 10.1177/1941874412438902

Marcoff, L., & Homma, S. (2014). Embolism, Cardiac and Aortic. Encyclopedia Of The

Neurological Sciences, 1-7. doi: 10.1016/b978-0-12-385157-4.00414-0

Arboix, A., & Alioc, J. (2010). Cardioembolic Stroke: Clinical Features, Specific Cardiac

Disorders and Prognosis. Current Cardiology Reviews, 6(3), 150-161. doi:

10.2174/157340310791658730

Cardiovascular System Anatomy and Physiology Retrieved from

https://nurseslabs.com/cardiovascular-system-anatomy-physiology/

American Heart Association (2022) How High Blood Pressure Can Lead to Kidney Damage

or Failure Retrieved from https://www.heart.org/en/health-topics/high-blood-pressure/health-

threats-from-high-blood-pressure/how-high-blood-pressure-can-lead-to-kidney-damage-or-

failure#:~:text=Over%20time%2C%20high%20blood%20pressure,to%20narrow%2C%20we

aken%20or%20harden.
Bordes et. al., (2020). Arterial Supply of the Thalamus: A Comprehensive Review. In

Arterial Supply of the Thalamus: A Comprehensive Review - ScienceDirect.

https://doi.org/10.1016/j.wneu.2020.01.237

Cerebrovascular Disease – Classifications, Symptoms, Diagnosis and Treatments. (2018).

Cerebrovascular Disease – Classifications, Symptoms, Diagnosis and Treatments.

https://www.aans.org/

Ackerman S. Discovering the Brain. Washington (DC): National Academies Press (US);

1992. 2, Major Structures and Functions of the Brain.

(https://www.ncbi.nlm.nih.gov/books/NBK234157/) Accessed 3/30/2022.

American Association of Neurological Surgeons. Anatomy of the Brain.

(https://www.aans.org/en/Patients/Neurosurgical-Conditions-and-Treatments/Anatomy-of-

the-Brain) Accessed 3/30/2022.

American Brain Foundation. Brain Disease.

(https://www.americanbrainfoundation.org/diseases/) Accessed 3/30/2022.

Myers, et al. (2004). Discharge planning process: applying a model for evidence-
based practice. 2004;19(2):123–9. https://pubmed.ncbi.nlm.nih.gov/15077829/