Intracerebra l Hemorrhage

Submitted by:
4NUR-6, RLE 3
MAGUILLO, Sharmaine Joy R.
MALIMBAN, Irish Queenie L.
MALLORCA, Mikaela Janelle D.
MAMAUAG, Keisha Alyssa C.
MANDAPAT, Rejane P.
MANECLANG, Wenn Joyrenz U.
MANGAOANG, Sabrina Alexandra M.
MANGINSAY, Liahnie Christine S.
MAPALO, Francesca Marie J.

Submitted to:
Geralynne G. Medrana, MAN, RN

September 04, 2018

Name: RAJ DOB: 8/31/1972 Age: 46
Sex: Male Civil Status: Single Address: Tanza, cavite
Religion: Roman Catholic Occupation: Technical Engineer

CC: Right Sided Weakness

Clinical Hx:
On August 4, 2018 at 3:00AM, the patient woke up his partner as he felt numbness and that he has an
elevated blood pressure. The patient asked for his medicine and took Clonidine (Catapres) urecalled dose. After
30 mins the patient experienced weakness on his right upper and lower extremities. No nausea and vomiting
was noted. He was immediately brought to MV Santiago Medical center (Trece, Cavite) at 4:00AM and was
assessed with GCS 7 (E1V1M5) and hs BP was noted to be 260/190. He was given anti-hypertensive medications
that resulted to decrease in his BP to SBP 240-220-200-190 mmHG. 4:20PM CT Scan was done and assessed at
hemorrhagic stroke on the let side of the brain. GCS improved to 9 (E3V1M5) and 11 (E4V1M6). They were
advised to transfer because of lack of facility and manpower. The patient was transferred to our institution at
3:30PM
On August 5, 2018, he was assessed with GCS7 and his BP was noted to be 260/190. He was given
unrecalled IV medications that resulted to decrease in BP to SBP 190mmHG. Ct Scan was done and assessed as
hemorrhagic stroke on the left side of the brain. They were advised to transfer due to lack of facility and
manpower. Hence, consult in our institution.

Personal / Social Hx:

Smoker 6-7 2pack years (5-6 sticks per day)stopped last 2014
Occasional alcoholic beverage drinker (6 bottles of beer per day)
Denies elicit drug use

Environment Exposure: Construction site

Past Medical History

Allergies: dried seafood

(+) Hypertension (2016) non-compliant with Telmisartan + Amlodipine 40/5 OD.

Clonidine 75mcg/tab OD and only taken as needed. UBP 160/90

(+) Kidney Stone (2017) took unrecalled medication

(+) Asthma last attack 2015 on Salbutamol and Ipatroprium bromide

Family Hx: Hypertension (parents)

Course in the ward:

8/6/2018 -NEUROLOGY-
6AM - Continue Nicardipine drip (20 mg in 80cc PNSS) to run at 30cc/hr
- Tofilac 30cc/hr
- For repeat Na @ 12nn

-CV-
6:40AM - Inform us on final OR plans
- Titrate Nicardipine drip with increment/decrement 2cc/hr maintain SBP 110-
170mmhg

-Nephro-
- Noted repeat Na
- Delay 12nn Na once available
-
8:45AM -CV-
- Nicardipine drip to follow 40mg in 60cc in PNSS to run at 50cc/hr
- To maintain SBP 120-140mmHg
- Declare CBG monitoring
- Start Lansoprazole 30mg OD
- Facilitate 2d echo with doppler once stable
- Inform on OR plans
- Aspiration precaution

9am -Nephro-
- Increase IVF rate PNSS to 80cc/hr
- Facilitate repeat Na at 12nn relay results once available
- No CA, ARB, NAIDS at all times

-Optha-
11:50AM - Asking main service if pt may be delayed and brought to San Damian

-CV-
12:30PM - Please include CBC in next blood extraction

-Neuro-
- May bring to san Damian

3:45PM Neuro
- -Give Myonal 50mg/tab TID
- Continue PT while admitted
- Passive ROM exercise c/o relatives
- Neurocognitive stimulation c/o relatives
-Neuro-
8:57PM - We will continue serial neuro exam
8/14/2018 -Nephro-
7am - Refer to Opthalmology this Am
- Maintaing feeding and flushing
- Ensure accurate I &O monitoring

-Rehab-
- We will continue OT and PT program today
- Continue upright position as tolerated
- Strictly no rem feeding

11am -CV-
- Continue IV meds
- Secure official 2d echo result and incorporate in chart
- Refer if with chest pain or hemodynamic instability

10PM -Optha-
• Pt seen and examined
• Assessment :
• No signs of retinopathy on time of examination, galucoma suspect both eye
• Plans:
Strict BP control, for perimetry 24-2 sit standard once abulto ambular, for compute
optha exam including factors visual
8/15/2018 Neuro-
5:15Am May give Paracetamol 500mg/tab

8AM Rehab Medicine-

Inquiring from other sevices if we may bring patient to center
We will continue with PT today

12:20PM -Nephro-
Facilitate KUBP UTZ today
Increase caloric value to1950 kcal/day

11:30AM -CV-
Continue present meds
Include CBC in blood extraction

8/17/18 -Nephro-
2:30PM Explained wife regarding RRT at this time still no consent
Wife denied and stick with medical therapy
8/18/18 -Nephro-
9:20AM Maintain IVF PNN @ 100cc/hr
11:05AM Accurate I &O monitoring
8:20pm -CV-
10:15PM • Noted repeat labs
• Increase Clonidine to 150mcg/tab q6
• Refer with SBP >140
-Neuro-
• Give Lactulose 30cc now
-Nephro
• Request for ABG
• Facilitate repeat labs on Monday AM
8/19/18 -NEURO-
8:30am • Discontinue lactulose
10:35am • Permanently refuses to hav RRT done and insists on giving
supplementary/alternative medicinefor the patient
11:50AM -CV-
• Plan to start a-blockers if with pesistent BP elevation
• Schedule anti-HPN meds:
• 1. Clonidine 150mcg/tab q6
• 2. Amlodipine 10mg/tab OD
• 3.Carvedine 25mg/tab BID

-Nephro-
Start NaHCO3 650mg/tab TID

8/20/18 -Rehab Medicine-

8:30am We will continue PT today
Strict DVT and bedsore prec
Encourage ROM exercises

10am -Neuro-
Maintain SBP 120-140mmHG
Bed turning q2h
Advised the relative to turn head from time to time to avoid neck stiffness

-CV-
11AM Continue monitoring BP
Refer if experiencing any sign and symptom of hypo/hypertension, chest pain,
dyspnea
Give:
Amodipine 10mg/tab OD
Clonidine 150mcg/tab q6h

11AM Nephrology-
Maintain IVF rate to 100cc/hr
Combine NaHCO3 1tab TID
9pm
-Neuro-
Please start Nicadipine drip 10mg in 90cc PNSS, titrate by increments and decrements
at 5cc/h to maintain SBP 12-140mmHg

08/21/2018 Neuro-
1:19am Continue Nicadipine drip 10mg in 90cc PNSS, titrate by increments and decrements at
5cc/h to maintain SBP 12-140mmHg
Hold feeding from now except meds
Continue to observe BM now

7:50AM -Nephro-
Please give due dose of Baclofen
Continue titrating Nicardipine drip to maintain < 160-190 if ok with cardio and neuro
Please inform us if patient will be maintained in NPO
Request for serum Crea, Na, K BUN
Continue Kalimate with NaHCO3

-Neuro-
9am May resume feeding if tolerated
Continue titrating Nicardipine to maintain SBP 120-140mmHg

-Nephro-
9am Continue titrating Nicardipine to maintain SBP <160-140mmHg
Facilitate lab request as ordered

-CV-
Continue IV meds
Refer if with chest pain or hemodynamic instability

8/22/2018 -Rehab Medicine-

8:20AM We will continue rehab program today with stable VS

10:20AM -Nephro-
Maintain IVF PNSS 100cc/hr
Continue NAHCO3 tab BID
Continue accurate I & O monitoring

10:50AM -CV-
Please initiate Nicardipine drip to maintain SBP 140mmHg
Plan to increase ISMN tomorrow
Start Lactulose 30cc ODHS starting tomorrow with BM >2x a day

6:30PM -Neuro-
Continue titrating Nicardipine drip to maintain 120-140 mmHg
Refer if there is neuro deficits
8/23/2018 CV-
3:00 PM Shift Ammlodipine to Nifedipine 60mgtab OD
Give another dose of ISMN 30mg increase to 60mg/tab at 12nn

4PM -Neuro-
Discontinue Baclofen
Bed turning q2h

8/24/2018 Rehab Med-

8:06AM Continue bed positioning and turning
12:00PM Encourage ROM exercises
DVT and bedsore prec
-Nephro-
• Decrease IV rate too 60cc/hr
• Repear Na, K, Crea, BUN, on Aug 28 4am
• Consume Kalimate 1 sachet OD
• Dulcolax suppository

8/25/2018 -Neuro-
2:50PM • May go home from neuro standpoint
4:20PM • Final Dx:
• Intracerebral hemorrhage Left putamen with IVE 35cc by
modifiedRotharinated, NIHSS 24 to 18 MS 4
• THM:
• Paracetamo 500mg tab q6 as needed for headache
• Lactulose 30cc ODHS, hold if BM >2x
-Neuro-
• Ff up after 2 weeks at neuro OPD (Sept 5. 2018)

8/25/2018 -Rehab Med-

7:50AM Continue bed positioning and turning
10:50AM Encourage sitting c/o relative
-CV-
• Final diagnosis: Hypertension, Stage II
• THM:
• Carvediene 25mg/tabBID
• Cemidine 150mg/tab q6h
• ISMN 60mg/tab OD
• Nifedipine 60mg/tab BID
11:40AM -Neuro-
4pm • Refer patient to dietary service for feeding interventions
• NOD to instruct relative on how to feed pt via NGT
• Continue PT while admitted
-Nephro-
• Consume IVF rate to 40cc/hr then consume
• Diagnosis: Acute kidney injury 2ndary to
• 1. Malignant hypertension-hypertensive emergency
• 2. Acute glomerulonephritis
 • Meds:
• Kalimate 1 sachet MWF while still admitted on dialysis
• NaHCO3 60mg/tab TID

8/26/2018 -Nephro-
10:40AM • Final Diagnosis: Acute kidney injury 2ndary to
• 1. Malignant hypertension-hypertensive emergency
• 2. Acute glomerulonephritis
• Medications NaHHCO3 650mg/tab 1tab OD
• Follow up at IM/Nephro OPD on Sept 3, 2018 with repeat Na, K, Crea, BUN,
CBC, urinalysis

-Optha-
• For complete opthalmologic examination if ok with main service and relatives
• Follow up opthalmology OPD same day as main seerial

8/27/2018 -Neuro-
9:45AM • For Crea BUN Na K in ffollow up at IM OPD on Sept 10, 2018
• Repeat urinalysis
• Increase Lactulose to 30cc/hr
• Kalimater1 sachet MWF whike still admitted on dialysis
• Immune dependency on nasal feeding c/o NOD
-CV-
• THM:
• Carvediene 25mg/tabBID
• Cemidine 150mg/tab q6h
• ISMN 60mg/tab OD
• Nifedipine 60mg/tab BID

-Nephro-
10:20 AM • Patient was seen and examined
• Diagnosis: Acute kidney injury 2ndary to
• 1. Malignant hypertension-hypertensive emergency
• 2. Acute glomerulonephritis
• Still advised renal biopsy
• For Crea BUN Na K in ffollow up at IM OPD on Sept 10, 2018
• Repeat urinalysis
• Give NaHCO3 1 tab TID
• Kalimate 1 sachet MWF while still admitted on dialysis

-Neuro-
4:20PM • Seen and examined
• Still for home from our standpoint
• Refer if with deccrease in sensorium on sensoria neological deficits.

8/28/2018 -Rehab Medicine-

8am • No objectives if for discharge from rehab, activities
• we will arrange for continue of PT and OT as outpatient
9:50 AM -Nephro-
• Still for home
• No objections on discharge plans
• Discharge Medications and Instructions as previously given
• For the meantime, maintain accurate I & O monitoring

-CV-
10:40AM • Still for discharge
• Discharge Instructions as previously given
• Increase oral flud intake
• Refer if with signs of hemodynamic instability

3:30 PM neuro
• Patient examined
• For plain cranial CT Scan as per relative’s report
• Still for home for standport
• Home meds as previously ordered
• Maintain SBP 120-140mmHg

8/29/2018 -Neuro-
12:10AM • Still for discharge
• We will continue neurological examination
• Refer accordingly

7:56 AM -Rehab Med-

• We will continue PT and OT while admitted
• Continue ROM exercises and upright position
• Strict DVT and Bedsore prec

9:00 AM -Nephro-
• Still no objective for discharge
• Suggest to give Dulcolax ssuppository
• If still admitted, please report Na, K, crea, BUN please relay resuls once
10:20AM available

-Neuro-
• Rule out nephro symptoms
• Report plain CT Scan noted
10:30AM • Continue medications while admitted
• Continue PT and OT while admitted

-CV-
Still for discharge
Discharge instructions as previously given
-Neuro-
Increase oral fluid intake
Refer if with signs of hemodynamic instabiity
 REVIEW OF SYSTEMS
GENERAL (-) fever, (-) weight loss, (-) weight gain, (-) weakness
SKIN Warm, slightly dry, good skin turgor
EYES (-) icteric sclera, (-) eye discharge
EAR (-) discharge, (-) deafness, (-) tinnitus
NOSE (-)epistaxis, (-)discharge, (-)obstruction, (-) sinusitis
MOUTH (-) bleeding gums, (-)fissures, (-) oral ulcers/sores
THROAT (-) tonsillitis, (-) hoarseness
NECK (-) neck stiffness, (-) dysphagia, (+) limitation of motion
PULMONARY (-) nonproductive cough, (-) dyspnea, (-) shortness of breath,
(-) colds
CARDIAC (-) chest pain, (-) palpitations, (-) cyanosis, (-) 2-pillow orthopnea, (-)
paroxysmal nocturnal dyspnea
VASCULAR (-) phlebitis, (-) varicosities, (-) claudication
GASTRO-INTESTINAL (-) nausea, (-) vomiting, (-) abdominal pain, (-) diarrhea,
(-) constipation, (-)heartburn
MUSCOLOSKELETAL (+) unsteady gait, (-) joint pain, (-) arthralgia, (+) right sided weakness, (-)
edema
ENDOCRINE (-) heat/cold tolerance, (-) polydipsia, (-) polyuria, (-)polyphagia
HEMATOPOIETIC (-) pallor, (-) gum bleeding, (-) easy bruisability
PSYCHIATRY (-) change of behavior

PHYSICAL EXAMINATION
Wt. (kg) 75 kg Ht. (cm) 170 cm BP (mmHg) 140/110 Temp 36.0
Pulse rate / character: 86 bpm, regular
Respiratory rate / pattern 20, regular
GENERAL SURVEY Drowsy, conscious, not in distress

NEUROLOGICAL SYSTEM
BEST EYE OPENING 4 Spontaneous
3 To speech
2 To pain
1 None
BEST VERBAL 5 Oriented
4 Confused
3 Inappropriate Response
2 Incomprehensible Sounds
1 None
BEST MOTOR 6 Obeys Command
5 Localizes Pain
4 Withdraws to pain
3 Flexor response
2 Extensions
1 None
 BLOOD CHEMISTRY
RANGE RESULTS IMPRESSION
08/16/18 08/20/18 08/26/18
UREA 9-23 mg/dL 84 55.50 42 A high BUN value can mean
NITROGEN kidney injury or disease is present.
Kidney damage can be caused by
diabetes or high blood pressure
that directly affects the kidneys.
High BUN levels can also be
caused by low blood flow to the
kidneys caused by dehydration or
heart failure.
CREATININE 0.67- 1.17 4.26 3.42 3.02 Elevated creatinine level signifies
mg/dL impaired kidney function or
kidney disease. As the kidneys
become impaired for any reason,
the creatinine level in the blood
will rise due to poor clearance of
creatinine by the kidneys.
Abnormally high levels of
creatinine thus warn of possible
malfunction or failure of the
kidneys
SODIUM 136-145 139 147 140 Hypernatremia involves
mmol/L dehydration, which can have many
causes, including not drinking
enough fluids, diarrhea, kidney
dysfunction, and diuretics. Mainly,
people are thirsty, and they may
become confused or have muscle
twitches and seizures.
POTASSIUM 3.5-5.1 5.64 5.04 3.63 The most common cause of
mmol/L genuinely high potassium
(hyperkalemia) is related to your
kidneys, such as: Acute kidney
failure or Chronic kidney disease
WBC 4.0-10 18 A high white blood cell count isn't
X10^9L a specific disease, but it can
indicate another problem, such as
infection, stress, inflammation,
trauma, allergy, or certain
diseases. That's why a high white
blood cell count usually requires
further investigation.
RADIOLOGY REPORT

▪ Cardiomegaly

➢ An atheroma is a reversible accumulation of degenerative material in the inner layer of an artery wall.
The material consists of mostly macrophage cells, or debris, containing lipids, calcium and a variable
amount of fibrous connective tissue.

▪ Atheromatous aorta

➢ An atheroma is a reversible accumulation of degenerative material in the inner layer of an artery wall.
The material consists of mostly macrophage cells, or debris, containing lipids, calcium and a variable
amount of fibrous connective tissue.

ULTRASOUND REPORT

• Normal sized kidneys with diffuse parenchymal changes

➢ Renal parenchymal disease means the same thing as chronic kidney disease(CKD). Is a condition
characterized by a gradual loss of kidney function over time.
• Renal cortical cyst, right upper pole
➢ Renal cysts are sacs of fluid that form in the kidneys. They are usually characterized as “simple” cysts,
meaning they have a thin wall and contain water-like fluid.
 ANATOMY & PHYSIOLOGY

What is basal ganglia stroke?

Your brain has many parts that work together to control thoughts, actions, responses, and everything that happens in your
body.

The basal ganglia are neurons deep in the brain that are key to movement, perception, and judgment. Neurons are brain
cells that act as messengers by sending signals throughout the nervous system.

What are the symptoms of basal ganglia stroke?

The symptoms of a stroke in the basal ganglia will be similar to symptoms of a stroke elsewhere in the brain. A stroke is
the disruption of blood flow to a part of the brain, either because an artery is blocked or because a blood vessel ruptures,
causing blood to spill into nearby brain tissue.

Typical stroke symptoms can include:

• a sudden and intense headache

• numbness or weakness on one side of the face or the body
• a lack of coordination or balance
• difficulty speaking or understanding words spoken to you
• difficulty seeing out of one or both eyes
Because of the unique nature of the basal ganglia, the symptoms of a basal ganglia stroke may also include:

• rigid or weak muscles that limit movement • difficulty swallowing

• a loss of symmetry in your smile • tremors
Risk factors for hemorrhagic stroke in the basal ganglia include:

• smoking
• diabetes
• high blood pressure

DESCRIPTION OF THE DISEASE

Intracerebral hemorrhage (ICH) Overview

Intracerebral hemorrhage (ICH) is caused by bleeding within the brain tissue itself — a life-threatening type of stroke. A
stroke occurs when the brain is deprived of oxygen and blood supply. ICH is most commonly caused by hypertension,
arteriovenous malformations, or head trauma. Treatment focuses on stopping the bleeding, removing the blood clot
(hematoma), and relieving the pressure on the brain.
Figure 1. An intracerebral hemorrhage (ICH) is usually caused by rupture of tiny
arteries within the brain tissue (left). As blood collects, a hematoma or blood clot forms
causing increased pressure on the brain.

An ICH can occur close to the surface or in deep areas of the brain. Sometimes deep
hemorrhages can expand into the ventricles – the fluid filled spaces in the center of
the brain. Blockage of the normal cerebrospinal (CSF) circulation can enlarge the
ventricles (hydrocephalus) causing confusion, lethargy, and loss of consciousness.

What are the symptoms?

If you experience the symptoms of an ICH, call 911 immediately! Symptoms usually
come on suddenly and can vary depending on the location of the bleed. Common
symptoms include:

• headache, nausea, and vomiting

• lethargy or confusion
• sudden weakness or numbness of the face, arm or leg, usually on one side
• loss of consciousness
• temporary loss of vision
• seizures

What is the NIH Stroke Scale?

The NIH Stroke Scale is a widely used tool that was built to assess the cognitive effects of a stroke. In more scientific
terms, it “provides a quantitative measure of stroke-related neurologic deficit” (NIH Stroke Scale).
Although the NIHSS was first developed as a clinical tool for research on stroke patients, it is now used by health
professionals to determine the severity of a stroke. It also helps create a common language between all people involved in
a stroke patient’s treatment. In a treatment setting, the scale has three major purposes:
• It evaluates the severity of the stroke
• It helps determine the appropriate treatment
• It predicts patient outcomes.

How is the NIHSS used?

The scale is made up of 11 different elements that evaluate specific ability. The score for each ability is a number between
0 and 4, 0 being normal functioning and 4 being completely impaired. The patient’s NIHSS score is calculated by adding
the number for each element of the scale; 42 is the highest score possible. In the NIHSS, the higher the score, the more
impaired a stroke patient is.

How well does the NIHSS predict patient outcomes?

Multiple studies have shown that the NIHSS predicts patient outcomes quite accurately, except in cases where the stroke
was isolated to the cortex area of the brain, in which case the prediction is a little less accurate.
As a general rule, a score over 16 predicts a strong probability of patient death, while a score of 6 or lower indicates a
strong possibility for a good recovery. Each 1-point increase on the scale lowers the possibility of a positive outcome for
the patient by 17 percent.

Why is the NIHSS score important for patients?

The NIHSS score is important for patients because it determines the course of action and treatment following a stroke.
First, healthcare staff apply the NIHSS score as soon as possible after the onset of symptoms—which would typically be
in the emergency department of a hospital. It will also be applied at regular intervals, and/or whenever the patient’s
condition changes significantly.
It’s important to keep a good history of a stroke patient’s NIHSS score because it allows healthcare professionals to
monitor their progress, tailor their treatment, and quantify their improvement or decline over time.
 PATHOPHYSIOLOGY: Intra-Cerebral Haemorrhage

Precipitating Factors: Predisposing Factors:

✓ Hypertension: BP ✓ Age: 45 years old

Increase in blood 260/190 ✓ Sex: Male
pressure ✓ Vices: Alcohol ✓ Hereditary: Both
and smoking parents have hx
✓ Diet: Oily and of hypertension
Thinning of arterial walls salty foods
✓ Lifestyle:
Sedentary
Rupture of tiny
arteries

Releases blood to
Signs and Symptoms: brain tissues

Due to Ruptured Arteries in

Left Hemisphere of Brain: Formation of
hematoma
✓ Right Hemiplegia:
(Sudden weakness of
right upper and lower Increase Intracranial
extremities) pressure
✓ Unstable gait
✓ Cold sweats
✓ An episode of
Deprivation of oxygen in
incontinence
that area: ischemia
✓ Aphasia: (sudden
slurring and loss of
speech)
Brain cells are affected
✓ Difficulty swallowing

Due to Brain Tissue Hypoxia:

Brain tissue necrosis
✓ Altered level of
consciousness: GCS 7

Irreversible brain
damage
 MEDICATIONS

NAME DOSE INDICATION MECHANISM OF ACTION CONTRAINDICATI NURSING RESPONSIBILITIES

ON

AMLODIPINE 10mg / Management Anti-hypertensive Contraindicated • Monitor BP frequently during initiation

tab of hypertension in patients of therapy. Because drug induces
Calcium channel blockers hypersensitive to vasodilation has gradual onset.
drug • Advise patient that abrupt withdrawal of
drug may increase frequency and
Systemic Inhibits calcium ion influx duration of chest pain. Taper dose
vasodilation across cardiac smooth gradually under medical supervision
resulting in muscles, dilates coronary
decreased BP. arteries and arterioles, and
decreases BP and
myocardial oxygen demand

CARVEDILOL 25mg / Carvedilol is Antihypertensive Contraindicated • Tell patient to take drug with food.
tab used to treat in those with • Tell patient not to interrupt or stop drug
heart failure and Beta blockers bronchial asthma without medical approval
high blood or related • Take apical pulse before administering. If
pressure bronchospastic <50 beats per minutes or I arrhythmia
Blocks the stimulation of conditions, occurs, withhold medication and notify
beta1 (myocardial) and beta second-or-third health care provider
Decreased heart 2 (pulmonary, vascular and degree AV block • Advise patient to change positions
rate and BP. uterine) – adrenergic and severe slowly to minimize orthostatic
Improved receptor sites. Also has bradycardia hypotension, especially during initiation
cardiac output, alpha 1 blocking activity of therapy or when dose is increased
slowing of the which may result in • Advise the patient to notify health care
provider if slow pulse, difficulty
 progression of orthostatic hypotension. breathing, cold hands and feet,
HF and dizziness, confusion, rash occurs.
decreased risk
of death

PARACETAMOL 500mg Mild to Analgesics Drug can cause • Caution patient if signs and symptoms of
/ tab moderate pain acute liver failure, liver damage (illogical thinking, severe
with Para-aminophenol which may dyspepsia, jaundice, inability to eat,
pain/he derivatives require a liver weakness) occur.
adache transplant or
cause death.
Thought to produce Most cases of
analgesia by inhibiting liver injury are
prostaglandin and other associated with
substances that sensitize drug doses
pain receptors. Drug may exceeding
relieve fever through 4000mg/day and
central action in the often involve
hypothalamic heat more than one
regulating center acetaminophen-
containing
product.

Monitor for
reddening of the
skin, rash,
blisters, and
detachment of
the upper surface
 of the skin

BACLOFEN 10mg / Spasticity in Antispasticity Contraindicated • Give drug with meals to prevent GI
tab multiple in patients distress
sclerosis; spinal Gamma aminobutyric acid hypersensitive to • Caution patient/caregiver not to
cord injury derivatives drug discontinue therapy abruptly. May result
in fever, mental status changes,
Use cautiously in exaggerated rebound spasticity and
Hyperpolarizes fibers to patients with muscle rigidity.
impaired renal
reduce impulse • Advise patient to follow prescriber’s
transmission. Appears to function or
orders regarding rest and physical
reduce transmission of seizure disorder
activity
impulses from the spinal or when spasticity
cord to skeletal muscle, is used to
thus decreasing the maintain motor
frequency and amplitude of functions
muscle spasms in patients
with spinal cord lesion
Overdose s/s:
coma, dizziness,
lightheadedness,
diminished
reflexes,
vomiting,
hypotonia

LANSOPRAZOLE 30mg Short-term Antiulcer Contraindicated • Advise patient to report onset of

treatment of in hypersensitive black, tarry stools; diarrhea; or
symptomatic Proton pump inhibitors patients abdominal pain to health care
GERD. Healing professional promptly. Instruct patient
 and risk to notify health care professional
reduction of immediately if rash, diarrhea,
NSAID- Binds enzyme in the abdominal cramping, fever, or bloody
associated presence of acidic gastric stools occur and not to treat with
gastric ulcer. pH, preventing the final antidiarrheals without consulting
transport of hydrogen ions health care professional
into the gastric lumen • Instruct patient to take medication as
directed for the full course of therapy,
even if feeling better. Take missed
doses as soon as remembered
Diminished accumulation of
unless almost time for next dose; do
acid in the gastric lumen, no double doses.
with lessened acid reflux.
Healing of duodenal ulcer
and esophagitis

NICARDIPINE 60mg/t Management of Antihypertensives Use Cautiously • Monitor BP and pulse prior to therapy
ab hypertension in: Severe ,during dose titration, and periodically
Calcium channel blockers hepatic throughout therapy. Monitor ECG
impairment periodically during prolonged therapy.
(dose • ● Monitor intake and output ratios
Inhibits the transport of recommended); and daily weight. Assess for signs of
calcium into myocardial and Severe renal HF (peripheral edema, rales/
impairment crackles, dyspnea, weight gain,
vascular smooth muscle
(dose may be jugular venous distention).
cells, resulting in inhibition
necessary) • Monitor serum potassium
of excitation-contraction
periodically. Hypokalemia risk of
coupling and subsequent
arrhythmias; should be corrected.
contraction

Systemic vasodilation
 resulting in decreased
frequency and severity of
attacks of angina.

OMEPRAZOLE 40 To treat It interferes with gastric Hypersensitivity • Advise patient to notify prescriber
mg/IV gastroesophage acid secretion by inhibiting to omeprazole, immediately about abdominal pain or
al reflux disease hydrogen-potassium- other proton diarrhea
(GERD) without adenosine triphosphate pump inhibitors, • To give drug via NG tube, mix granules in
esophageal (H+K+-ATPase) enzyme or their acidic juice because enteric coating
lesions to system, or proton pump, in components dissolves in alkaline PH.
prevent erosive gastric parietal cells. • Encourage patient to avoid alcohol,
esophagitis aspirin products, ibuprofen, and foods
that may increase gastric secretion
during therapy.

LACTULOSE 30 cc To treat Arrives unchanged in the Hypersensitivity • When giving lactulose by retention
constipation colon, where it breaks down to lactulose or its enema, use a rectal tube with a balloon
into lactic acid and small components, low to help patient retain enema for 30 to 60
amounts of formic acid and galactose diet minutes. If not retained for atleast 30
acetic acids, acidifying fecal minutes, repeat dose. Be sure to deflate
contents. Acidification leads balloon and remove rectal tube after
to increased osmotic completing administration.
pressure in the colon, • Monitor diabetic patient for
which, in turn, increases hyperglycemia because lactulose contain
stool water content and galactose and lactose
softens the stool. Also, • Plan to replace fluids if frequent bowel
lactulose makes intestinal movement cause hypovolemia
contents more acidic than • Instruct patient to report abdominal
blood. This prevents distention or sever diarrhea
ammonia diffusion from • Advise diabetic patient to check blood
 intestine unto blood, as glucose level often and to report
occurs in hepatic hyperglycemia.
encephalopathy. The
trapped ammonia is
converted into ammonia
ions and by lactulose’s
cathartic effect, is expelled
in feces with other
nitrogenous wastes

CLONIDINE 150 To manage Stimulates peripheral alpha- Anticoagulant • Monitor blood pressure and heart rate
mg/1 hypertension adrenergic receptors in the therapy (epidural often during clonidine therapy.
CNS to produce transient infusion); • Be aware that stopping drug abruptly
tab vasoconstriction and then bleeding can elevate serum catecholamine levels
stimulates central alpha- diathesis; and cause such withdrawal symptoms
adrenergic receptors in the hypersensitivity such as nervousness, agitation,
brain stem to reduce to clonidine or its headache, confusion, tremor and
peripheral vascular components rebound hypertension
resistance, heart rate, and
systolic and diastolic blood
pressure.

KALIMATE 1 Prevention and After administering Patients with • Monitor serum potassium and serum
sachet treatment of Kalimate is exchanged for intestinal calcium levels regularly to prevent
hyperkalemia potassium ion in the obstruction and overdose.
resulting from intestinal tract, particularly stenosis, • It may cause colon necrosis, colon ulcer
acute or chronic around the colon and the constipation if administered per orem
renal failure frug is excreted as
unchanged polusterene
sulfonate resin into the
 feces without digestion and
absorption. In consequence,
potassium in the intestinal
tracts excreted outside the
body.

PARACETAMOL 300 For pain Through the produce Hypersensitivity • Administer to patient after meals
mg/IV treatment/Analg analgesia by blocking pain to • Assess patient’s pain: type of pain,
esics impulse by inhibiting acetaminophen location, intensity, duration
synthesis of prostaglandin or phenacetin; • Assess allergic reactions: rash, urticaria,
in NCS that synthesize pain use with alcohol if these occur, drug may have to be
receptor to stimulation discontinued
• Instruct the patient to notify the
physician for pain lasting for more than
3 days.
Discharge Plan

MEDICATION
 Instruct patient to take the following take home medications at the right time, dose,
frequency and route
1. Paracetamol 500mg/tab 1tab q4 PRN-for headache and neck stiffness
2. Amlodipine 10mg/tab 1 tab OD - to control hypertension
3. Carvedilol 20 mg/tab 1 tab q12 - to control hypertension
4. Clonidine 150mg/tab 1 tab q6 – to control hypertension
5. Kalimate sachet 1 sachet OD – for hyperkalemia (kidney stones)
6. Baclofen 10 mg/tab 1 tab BID – for muscle spasms (stiffness)
 Encourage to comply with the medications to prevent complications
EXERCISE
 Encourage patient to do 30 minutes of walking as a form of exercise.
 Encourage to perform ROM exercises. Active ROM exercises increase muscle
mass, tone, & strength pressure joint mobility & improve cardiac & respiratory
function.
 Instruct patient to dangle the legs from the bed side for 10 to 15 minutes to prevent
orthostatic hypotension
 Encourage patient to perform exercise more slowly, in a longer time with more rest
or pauses, or with assistance if necessary. This helps in increasing the tolerance for
the activity.

TREATMENT
 Emphasize the importance of regular BP monitoring
 Instruct to wear compression stockings to prevent deep vein thrombosis (DVT)
 Instruct to have adequate rest and sleep

HYGIENE
 Instruct to take a bath everyday, brush teeth, wash hands before and after eating
 Advise to keep the environment clean

OUTPATIENT
 Emphasize importance of follow-up check ups
 To come back at September 7, 2018 for rehabilitation
 To come back on September 28, 2018 for follow-up check-up at USTH CD
DIET
To promote a full recovery,
 Advise patient to limit fats, cholesterol and sodium in the diet
 Encourage to eat more fruits and vegetables, whole grain foods, fish, poultry and
nuts
 Encourage to drink 8-10 glasses of water to keep the body hydrated
SPIRITUAL, SOCIAL, SEXUAL, PSYCHOLOGICAL
 SPIRITUAL
 Encourage to continue to seek God’s guidance and enlightenment
 Emphasize the importance of prayers in healing
 Encourage to keep faith in God and not to give up easily during difficult times
 SOCIAL
 Encourage attendance in group activities
 Encourage re-establishment of relationship with significant ones
 SEXUAL
 Assess sexual history of client to determine needed education and intervention
 Encourage patient to address concerns about sexual needs, sexuality, and
sexual relationship
 Educate about the factors such as hormonal changes, disease and illnesses that
can affect sexual function
 PSYCHOLOGICAL
 Encourage patient to express feelings to family and friends
 Encourage patient to express feelings through non-stimulating activities like
drawing, and writing