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    This document provides a patient profile, history, examination results, diagnosis, treatment plan and discharge instructions for Baguna,Nonito Taruza, a 56-year-old male admitted for a cerebrovascular accident (CVA). The patient has a history of smoking and drinking. Examinations show infarcts in the right side of the brain. The treatment plan includes medications, exercises and health education. Upon discharge, the patient will follow-up at the outpatient department and continue a low salt, low fat diet.

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    Patient

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    kcquitoriano
    55 views9 pages
    This document provides a patient profile, history, examination results, diagnosis, treatment plan and discharge instructions for Baguna,Nonito Taruza, a 56-year-old male admitted for a cerebrovascular accident (CVA). The patient has a history of smoking and drinking. Examinations show infarcts in the right side of the brain. The treatment plan includes medications, exercises and health education. Upon discharge, the patient will follow-up at the outpatient department and continue a low salt, low fat diet.

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    This document provides a patient profile, history, examination results, diagnosis, treatment plan and discharge instructions for Baguna,Nonito Taruza, a 56-year-old male admitted for a cerebrovascular accident (CVA). The patient has a history of smoking and drinking. Examinations show infarcts in the right side of the brain. The treatment plan includes medications, exercises and health education. Upon discharge, the patient will follow-up at the outpatient department and continue a low salt, low fat diet.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    55 views9 pages

    Patient

    Uploaded by

    kcquitoriano
    This document provides a patient profile, history, examination results, diagnosis, treatment plan and discharge instructions for Baguna,Nonito Taruza, a 56-year-old male admitted for a cerebrovascular accident (CVA). The patient has a history of smoking and drinking. Examinations show infarcts in the right side of the brain. The treatment plan includes medications, exercises and health education. Upon discharge, the patient will follow-up at the outpatient department and continue a low salt, low fat diet.

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    Patients Profile

    Name: Baguna,Nonito Taruza Birthdate: April 21,1955 Age : 56 yrs old Birthplace: Antique Nationality: Filipino Religion : Catholic Address:#1 Marton East, Canumay, Valenzuela City Admission Date: 9/15/2011 11:40 am

    Patients History
    Baguna Nonito 56 y/o, Married, Roman Catholic, Tricycle Driver, permanently residing at # 1 Marton East, Canumay, Valenzuela City Mr. Baguna started smoking and drinking alcohol at the age of 17. Past History: (+) HPN (-)DM (-) PTB (-) Asthma

    Drug Allergies: none Other Allergies: none

    Pathophysiology

    Predisposing Factor Precipitating factor *age *Lifestyle *gender *smoking * alcohol drinking

    Hypertension Increase shearing force Damage of arterial endothelial layer Inflammatory response And intramuscular clotting

    Hyperlipidemia

    Thrombus formation

    Narrowing of the lumen Disrupted brain cell metabolism Increase ICP Localized acidosis and free radical formation CVA infarct

    Laboratory Results
    CT Scan Result Examinations : Head CT scan Plain (CVA) Interpretations: Plain Ct scan of the head shows as low attenuation value leson in the right lentiform nucleus, caudate nucleus and right internal capsule. Midline Stuctures are in place posterior fossa is unremarkable. Impression: Infarcts, right lentiform, caudate and internal capsule. Chest X-ray Examinations : Chest AP Interpretation: The lung fields are clear heart is not enlarged, Both Hemidiaphragmsare intact. Impression: Normal chest

    Hematology Hemoglobin Hematocrit RBC count WBC count Platelet count Neutrophiles Lymphocytes Glucose Cholesterol HDL Cholesterol LDL Cholesterol Triglyceride

    Result form 135 g/L 0.42 g/L 4.53 x 10/L 9.2 x10 /L 260x10/L 0.68 0.32 6.67mmol/L 3.84mmol/L 0.5mmol/L 2.88mmol/L 1.12mmol/LD High Normal Low Normal normal

    Reference Value 125-160 0.38-0.50 4.5-5.5 5.0-10.0 150-400 0.40-0.60 0.20-0.40 3.845.83 <=5.20 0.9-1.9 1.704.60 <=1.70

    DRUG NAME PIRACET AM

    MECHANSM OF ACTION The drug influences neuronal and vascular functions and influences function without acting a sedative or stimulant. Reduction in blood pressure occurs independentl y of the status of the rennin angiotensin system

    INDICATION S Indicated in the conditions like adaptation disorders, cerebral impairment cerebrovasc ular accident. Indicated in the conditions like CHF, Diabetic neprophaty in type 2 DM, HPN

    SIDE EFFECTS Piracetam has been found to have very few side effects and those it has are typically few mild and transient. Acute overdosage of the losrtan hypotensio n, tachycardia , dizziness nausea,diar rhea,myalgi a,abdomina l pain,dyspe psia,backac he,muscle pain Peripheral edema,sinu s bradycardia ,braddyarrh tymias,flatu lence,dizzin ess,vertigo, drowsiness, fatigue,nau sea,vomitti ng

    CONTRAINDICATI ONS Contraindicated in conditions like liver disease, pregnancy, breast feeding.

    NURSING CONSIDERATIONS

    >Monitor possible drug reaction

    Losarta n

    Contraindicated in conditions like aldosteronism, renal artery stenosis,hypersen sitivity

    >Assess patients blood pressure before giving medication. >Assess for hydration status. >Assess BP with position changes. >Monitor possible drug reaction.

    Amlodip ine

    Calcium ion antagonist that inhibits the transmembr ane influx of calcium ions into vascular smooth muscle and cardiac muscle

    Indicated in conditions like Angina pectoris essential hypertensio n

    Contraindicated in conditions like aortic stenosis,sinoatrial node disease,hypersen sitivity.

    >Assess fluid status >Do not confuse amlodipine with amiloride >Instruct patient to take drug exactly as prescribed >Advise patient to avoid sudden changes in position to prevent dizziness, light headedness or fainting.

    Nursing Care Plan


    ASSESSMENT S: Ang hirap lumunok kapag kumakaen ako O: T= 36.2 RR= 20 PR= 66 BP=130/80 The patient is drooling when in a side lying position > The patient is having a hard time swallowing >The patient has an ability to chew DIAGNOSIS Risk for aspiration to ineffective swallowing mechanism PLANNING After 1 hour of Nursing Intervention the patient will decrease or no risk for risk aspiration INTERVENTIO N 1.Monitor and records vital signs 2.Explain treatment to the patient and significant others 3.Stop feeding immediately if you suspected aspiration. Then apply suction and turn patient on the side 4. Elevate head of the bed 90 degrees RATIONALE >To detect sign of aspirations or impaired gas exchange due to respirations > to encourage compliance >To prevent aspiration EVALUATION After 1 hour of Nursing intervention the patient was able to decrease or no risk for aspiration

    >decrease the risk for aspiration

    ASSESSMENT

    DIAGNOSIS

    PLANNING

    INTERVENTION

    RATIONALE

    EVALUATION

    S: Hindi maintindihan ang salita niya para ba siyang bulol as verbalized by patients son O: T= 36.2 RR= 20 PR=66 BP=130/80 >speaks and verbalized with difficulty >Difficulty in comprehending ASSESSMENT

    Impaired verbal communicatio n related to cranial nerve dysfunction

    After 8 hours of nursing intervention the patient will established a method of communicatio n in which his needs can be expressed

    1.Facilitate hearing and vision examinations, obtaining necessary aids. 2. use non verbal methods of communicatio n

    >When needed/desire d for improving communication

    >To reinforce your words

    After 8 hours of Nursing Intervention the patient was able to establish a method of communication in which his needs can be expressed

    DIAGNOSIS

    PLANNING

    INTERVENTIO N 1.Identify interventions of safety devices 2.Keep side rails up for patients with hemipleghia and hemiperesis 3.Observe for factors that may cause or contribute to injury

    RATIONAL E >to promote physical environmen t and individual safety >to protect patient from rolling out of bed >To increase awareness of patient ,family members and caregivers

    EVALUATION

    O: Weakness of left side of the body >motor impairment >decrease sensorium and maintaining the usual communication pattern >inability to modulate speech

    Risk for injury Related to left sided Body weakness

    After 2 hours of Nursing Intervention the patient will be able to help identify and apply safety measure to prevent injury.

    After 2 hours of Nursing Interventions the patient was able to identify aand apply safety to measure to prevent injury.

    Discharge Planning
    Medications: Clopidogrel 75mg tab once a day 8pm Amlodipine 5mg tab once a day 8am Losartan 5mg tab once a day 1pm B-complete tab once a day 8am Exercises The patient can perform active and passive ROM of exercise such as walking daily in an increasing distance and time as prescribed. The patient can perform flexion and extension of fingers and legs to improve hand and leg muscle for better grip and handling. Treatment To continue prescribed home medications, to performed indicated exercises to participate in counselling to improve self-esteem; decrease life anxiety to encourage family to have family therapy that wll help the patient for faster recovery of physical and mental health. Health Teaching

    Provide positive reinforcement during activity. Patients may be reluctant to move or initiate new activity due to fear of falling. Avoid activities that tense muscle; isometric exercises, weight lifting, any activity that r4equires sudden burst of energy Avoid physical exercises immediately after a meal. Stop smoking and use of tobacco Avoid second hand smoke Teach energy saving techniques. There optimized patients limited services.

    Outpatient Department (Follow-up check-up) To participate in weekly follow-up check-up at the Valenzuela Medical Center. To participate on indicated Rehabilitative therapy. Diet Low salt, Low fat diet.

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