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Quezon Medical Mission Group Hospital and Health Services Cooperative Roeder Max R. Pangramuyen CI -Mrs. Melena V.

. Quintos Related Learning Experience BSN IV SLSU Group 7

CASE NARRATIVE
Cerebrovascular Accident is caused by disruption of the blood supply to the brain causing neurologic deficit. More than its definition, there are lots of things to be remembered upon handling patient who had CVA. The care must be holistic and the approach to patient must be based on his/her needs.

In the third week of exposure, I handled patient on bed 240, Mr. Josefino Alladel, a 52 year old male, born on October 2, 1960, Roman Catholic, married man, with chief complaint upon admission of pain/numbness on right upper extremities. He was admitted last August 11, 2013 at around 3:40pm under the service of Dr. Lumabi and with co management of Dr. Tabio, initial diagnosis was CVA, and nothing per orem was ordered.

Prior to admission, the client was on the cockpit arena, and after the match as the patient was on his way home, some of his friends noticed that he walks unbalance, swaying a little and suddenly fall on the ground. His friends quickly send him to QMMG-HHSC.

Upon admission on August 11, 2013 Dr. Lumabi ordered him to admit on NS 2, different diagnostics examinations were ordered such as CT scan, 12LECG, BUN, creatinine, CBC, CXR PA, urinalysis, FBS, RBS, blood uric acid, and lipid profile, As well as different medications were ordered. The pt was hooked with 1L of PNSS x KVO. NGT was inserted, and oxygen was given via nasal canula and regulated at 2-3lpm. Initial GCS score was 7; E1, V1, and M5. Intake and output were carefully regulated every shift. According to Dr. Tabio CT scan revealed ICH (intracranial hemorrhage) left temporoparietal area approximately 10cc. Pt was closely monitored for signs of progression of neurologic deterioration and report it as necessary.

August 12, 2013, was the start when I handled the patient. Upon my assessment patients GCS was still 7; E1 pupil size were 3-4mm, V1, and M5 and had flexion withdrawal upon pain stimulus. The patient was still hooked in his 1st bottle of PNSS, oxygen was given

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Quezon Medical Mission Group Hospital and Health Services Cooperative


via nasal cannula regulated at 2lpm, since pt. was unconscious and he cannot receive nutrition by mouth, nasogastric tube was inserted at left nostril and it was patent and intact upon auscultation, he also had foley catheter connected to urine bag and it drained yellowish urine moderate in amount. Patient had right hemiparesis, spits sputum, had crackles sound heard on both lung fields upon auscultation, negative bowel movement, with cold and clammy skin.

Based on history taken from patients relative, she revealed that the patient was diabetic since 40 years old (had diabetes for almost twelve years), and medications as maintenance were taken. Also the patient had 4 mild attacks of stroke, and the 5 th attack happen last February and the patient was admitted at Mt. Carmel Hospital, that time the affected part was left. The patient stopped all his vices including drinking alcohol, smoking and eating too fatty and salty foods, except of playing sabong. This happened to be the 6th attack and the most severe. Patients mother was hypertensive and his father had diabetes and died due to liver damage.

Due to result of CT scan, Intracranial Hemorrhage of left temporoparietal area approximately 10cc, Citicoline 1gm IV q8 was given as brain stimulant due to deteriorating level of consciousness and Mannitol 20% 100cc IV bolus q4 with BP precaution was given to eliminate and decrease cerebral edema because it was the only diuretics which crosses the blood brain barrier. Careful monitoring of GCS and level of consciousness, as well as intake and output were done. Patient was positioned on semi fowlers position, while avoiding frequent turning of patients head (to avoid further increase of ICP). There is marked elevation on patients blood pressure and widening pulse pressure. Frequently the BP of the patient was between 140-170/80-100 mmHg. Nicardipine drip: 90cc of PNSS + 1amp of Nicardipine 10mg x 25mgtts/min to titrate for BP at least 140-150 mmHg. BP monitoring was done every hour and Nicardipine was titrated as BP reached higher than 140/80 mmHg. Combizar 50/12.5mg 1 tablet OD a combination of Losartan and Hydrochlorthiazide (antihypertensive and diuretics) was provided in 8am, amlodipine (Amivasc) 5mg/tab 1tablet OD in am an anti- angina medication which inhibit ion influx across cardiac and smooth muscle cells, thus decreasing myocardial contractility and oxygen demand, which also dilates coronary arteries and arterioles. Finafibrate (lifezar SR)

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Quezon Medical Mission Group Hospital and Health Services Cooperative


2g 1 cap BID post supper was given as antihypertensive which acts by inhibiting vasoconstrictive and aldosterone secreting action of angiotensin II. CBC results were as follows: Hgb. 98mg/dl, Hct 0.29, RBC 3.24 x 10^12L, WBC 13.1 10^g/L, and platelet count is 271 10^g/L. Results indicate altered tissue perfusion and maybe related to decrease cerebral perfusion and continuous oxygenation was given.

Blood chemistry results were as follows: FBS 132.13 mg/dl which indicates hyperglycemia and since the patient was diabetic different medications were given. Insulin gargline (Lantus solortan) inject 20 u SC at 10pm daily, Novorapid 5 u IV for CBG > 200mg/dl an isulin aspart, and Trajenta 5mg/tablet 1 tablet OD in AM was given at 8 am. Medications mentioned above work to aid in lowering blood glucose level. BUA 8.2 mg/dl indicates hyperuricemia, and an allupurinol (Prizol) 300mg /cap 1cap OD antigout drug which reduces uric acid production was administered at 8pm. HDL 45.02 mg/dl and LDL 103.8 mg/dl were both within normal levels except triglyceride 175.55 mg/dl which indicates hypercholesterolemia, rosuvastasin (Rosvin) 20mg 1tab ODHS an antilipemic was given at 8 pm. Rosuvastatin acts by inhibiting HMG-COA reductase, increases LDL receptors or liver cells, and inhibits hepatic synthesis of VLDL.

BUN was 100.04 mg/dl, and Creatinine 3.6 mg/dl which indicates impaired kidney function. It can be due to diabetic nephropathy one of micro vascular complications of DM. RBS 128 mg/dl, SGOP 32 mg/dl, SGPT 24 mg/dl, K 5.27 mmol, and Na 142.6 mg/dl were all within normal limits. Ketosteril 600mg/cap 2 capsules TID a combination of ketoanalogues and amino acid were used as supplement to limit used of amino acid in the body and to prevent atrophy. Paracetamol 500mg/tab 1 tab prn for fever was also being ordered.

On rounds of Dr. Tabio on Aug 12 , he ordered for repeat CT scan, follow an IVF of 3 bottle of PNSS at 20 mggts/min regulation, bed sore precaution and Apply (hexetidine) Bactidol oral hygiene at least 4 times a day. Bactidol was given before each feedings or at least 1 hour after feeding, and used as oral hygiene to avoid foul smelling odor of the patient, he was unconscious, cannot have his own oral care and he take his food via NGT. The patient was carefully turned side to side at least every two hours, provide back

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Quezon Medical Mission Group Hospital and Health Services Cooperative


massage and tapping, application of powder and stretching bed linens was done to avoid formation of bed sores. During assessment there are marked changes on patients level of consciousness GCS ranging from 8-10. He also started to have crackles sound and spit sputum.

Urinalysis result shows risk for urinary tract infection. There are presence of pus cells 4-8 hpf, few crystal A. urates, epithelial cells, and bacteria. ceftriaxone (keptrix)1gm IV OD no skin testing needed and clindamycin 300mg/cap 1cap TID were ordered on Aug 13 and were both administered to inhibit cell wall synthesis and bacterial protein synthesis. These two medications were both used to treat UTI. August 13, 2013 last day of handling this pt., since that pts S.O. cannot provide money for CT scan, Dr. Tabio explained that on admission 10cc of blood were seen and he wants to see if the blood progress up to 30cc which can indicate severe cerebral damage. On the same day patient eyes open to vigorous stimulation, makes incomprehensible sounds, still with right hemiparesis, pupils size range from 3-4mm, and pupils reactive to light.GCS was still 8-10. Medications were given with osteorized feeding and the client tolerated it well.

Upon handling these client I was able to provide a care which maybe different upon handling clients on other rooms. Rapport was built with the relative that help to make the work lighter. I mastered NGT feeding with correct applications of principles upon feeding. I was also reminded of importance of careful monitoring of pts level of consciousness, GCS, I & O, and vital signs. I also able to apply my plan of care based on patients needs. I handled patients with CVA many times, and even though I already mastered it, I still learn something upon handling a new one. I am very thankful that as student nurse I was able to use my nursing skills, knowledge, attitude and judgment in helping those clients who are waiting for our service.

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