A Case Study On Cerebrovascular Accident With Kristy Garvez Genward 2023 Goods Na Guro Ni

THE COLLEGE OF MAASIN
"Nisi Dominus Frustra"

College of Nursing & Allied Health Sciences
A CASE STUDY ON CONGESTIVE HEART FAILURE

A.Y. 2023-2024
Presented to:
Mrs. Glady’s Reina M. Maitem, RN
Faculty of the College of Nursing the College of Maasin
Presented by:
Andrea Alex Apego
Donnabel Kristy Garvez
Grafia, Joshua S
Glesh Fe Llevares
BSN IV Group III
October 10, 2024

INTRODUCTION
Patient F.A.O was admitted at Consuelo Tan due to loss of consciousness for
a few minutes. Assessment findings noted body weakness and aphasia and was
subsequently referred to LH hospital.
EPIDEMIOLOGY
Stroke is the Philippines' second leading cause of death. It has a prevalence of 0·9%;
ischemic stroke comprises 70% while hemorrhagic stroke comprises 30%. Age-adjusted
hypertension prevalence is 20·6%, diabetes 6·0%, dyslipidemia 72·0%, smoking 31%, and
obesity 4·9%. The neurologist-to-patient ratio is 1:330·000, with 67% of neurologists
practicing in urban centers. Health care is largely private and the cost is borne out-of-pocket
by patients and their families. Challenges include delivering adequate support to the rural
communities and to the underprivileged sectors.
Each year CVD causes an estimated 17 million deaths worldwide, accounting for
one-third of all deaths worldwide. More than one-third of these deaths occur in middle-aged
adults. In developed countries heart disease and stroke are the first and second leading
cause of death among adult men and women.
However, the burden of CVD in developing countries has increased significantly. Twice as
many deaths from CVD occur in developing countries as in developed countries. Overall, in
developing countries CVD ranks third in disease burden. By 2010 CVD is estimated to be
the leading cause of death in developing countries. CVD are the main cause of death in the
UK, accounting for just under 233,000 deaths in 2003. More than 1 in 3 people (38%) die
from CVD. The main forms of CVD are coronary heart disease (CHD) and stroke. About half
of all deaths from CVD are from CHD and about a quarter are from stroke.
OBJECTIVES
GENERAL OBJECTIVES
After 2-3 hours of case presentation, the audience as well as the other students will be able to
obtain knowledge, build appropriate skills, demonstrate a good attitude, apply what they've learned,
and establish competent nursing management for a patient with Congestive Heart Failure.
SPECIFIC OBJECTIVES
After thoroughly discussing the case presented, the nursing students shall be able to:
• Determine the client's medical history, both past and present. Perform a thorough and precise
physical examination of the client in order to obtain baseline data.
• Trace and provide proper explanation for the development data of the client.
• Determine the causes, predisposing factors, and precipitating variables that contribute to the
disease process and development.
• Identify and review the anatomy and physiology of the different body systems affected by the
disease condition.
• Trace and thoroughly explain the pathophysiology (disease process) of Congestive Heart Failure.
Identify and explain the disease's various manifestations.
• Determine the patient's diagnostic examination, as well as the implications and nursing
responsibilities.
• Identify the client's fundamental and actual medications prescribed, including their mode of
action, side effects/adverse effects, indications, contraindications, and nursing responsibilities.
Identify and prioritize the client's needs.
• Formulate appropriate nursing care plans based on the data collected during the assessment
and identify needs and problems of the patient and render important health teachings.
• Evaluate complications to nursing practice, education, and research.
HEALTH HISTORY
A. Biographic Data
Name: Felicilda A.
Address: Barangay zone III Sogod So. Leyte
Date of Birth: May 2, 1950
Age: 73 years old
Sex: Female
Civil Status: Married
Occupation: N/A
Religion: Roman Catholic
Nationality: Filipino
Health Care Financing: PhilHealth
B. Chief Complaint / Reason for Visit:
Body weakness right
C. History of Present Illness
16hours prior sudden onset of lost of consciousness for a few minutes. Noted
body weakness, Right side and aphasia admitted in consuelo Tan and was
subsequently referred to this institution.
D. Past History
The patient has type 2 diabetes and hypertension
E. Family History of Illness
- The patient’s father’s side has a history of hypertension while her mother’s
side has hypertension and diabetes mellitus.

Female Father Patient

Male Mother Deceased
Mothers Side Fathers Side
Hypertension Diabetes Mellitus
Diabetes and Hypertension
Diabetes and Hypertension

PHYSICAL EXAMINATION
Vital Signs:
Temperature: 35.1 °C Pulse Rate: 66
Respiratory Rate: 19 Blood Pressure: 150/90 mmHg
General Appearance
 The patient has an altered sensorium

 O2 therapy at bedside via face mask
 The patient is using pursed lip breathing
 Cloths are appropriate for weather and location
 Patient has decreased reflexes
 Patient is restless
Mental Status
 The patient has altered levels of consciousness. The patients’ eyes opens
upon command, voice is none, and Obeys command with a total of GCS in 10
Skin, Hair
 Color is evenly distributed

 No lesions are found
 No paleness noted
 Hair is black
Head, Neck
 Head is symmetrically erect at midline

 No lesions visible
 Face is symmetric
 No abnormal movements noted
 No distended veins
 No smooth, tender, palpable nodes
 Does not use accessory muscles to aid in breathing
Eyes
 Eyes are equally round, reactive to light and accommodating

 Conjunctiva is clear and equal in size
 Cornea is transparent and smooth
 Eyelids close symmetrically, no discharges, lesions, and discolorations noted
 Not wearing corrective lenses
 Irises are brown, evenly colored and typically round
Ears
 Ears are symmetrical in shape

 No lesions found
 Small forms of cerumen are present
 No discharges present
 No foul odor noted
 No reports of tenderness or pain
Breast/Chest
 Symmetrical in shape with 1:2 ratio

 Intercostal spaces are not retracted
 No discoloration
Lungs
 Respiratory rate is 15cpm

 Pursed lip breathing noted
 No adventitious sounds heard upon auscultation
Heart
 Regular in rhythm
 Pulse rate is at 66bpm and blood pressure is 90/60 mmHg
 Weak stroke volume
 Equal on both sides of the body
Extremities
 Lower extremity edema noted + 2

 Capillary refill more than two seconds
 Body weakness noted
GORDON’S FUNCTIONAL HEALTH PATTERN
1. Health Perception-Health Management Pattern

A. Before Hospitalization
The patient states that health is important by eating healthy foods but
still does minimal exercise.
B. During Hospitalization
The patient is now at completely at bed rest and follows therapeutic
regimen.
2. Nutrition and Metabolic Pattern
The patient does her breakfast at 7:00am, lunch at 11 am she takes
her snacks at 3:00pm and dinner at 5:00pm. She mostly eats fish and
less rice
The patient is now at NGT feeding and has a schedule feeding every
6hurs.
3. Elimination Pattern
The patient urinates at least 4 times a day and defecates 3 times a
week.
The patient is now on FBC and defecates at least once per day.
4. Activity Exercise Pattern
The patient enjoys taking walks during early mornings.
The patient is at bed rest and is ordered to turn to sides every 2 hours.
5. Sleep-Rest Pattern
The patient sleeps at 8 pm and wakes up at 4 am.
The patient now sleeps most of the time.
6. Cognitive-Perceptual Pattern
The patient has a slight difficulty in seeing, she can hears clearly and
speaks fluently before 16hours prior to admission.
The patient only opens her eyes on command and has an Impaired
communication and is sleeping most of the time.
7. Self-Perception Pattern
The patient views herself as someone who eats healthy but does not
exercise because she easily gets tiered in doing physical activities.
The patient now under monitoring and cannot communicate.
8. Role Relationship Pattern
The patient mostly spends her time with her husband since her
daughters and sons now lives separately and now have a family on
their own
The patient’s daughter and husband are the one monitoring her since it
is difficult from other family members to visit her due to the distance
and their schedule.
9. Sexuality and Sexual
The patient has no longer engages in sexual intercourse due to easily
get tiered
The patient cannot engage sexual intercourse due to her medical
condition.
10. Coping Stress Management Pattern
The patient copes with her problems by watching television
The patient sleeps to relieve stress.
11. Value Belief System
The patient does not go to church every Sunday but still prays at her
home
The patient cannot go to church due to her condition.
DEVELOPMENTAL TASKS
A. ERIK ERIKSON’S DEVELOPMENTAL STAGE
STAGE BASIC ACTUAL

Ego Integrity Vs. Despair At this stage of life, individuals feel they have The patient is content according to her
lived a fulfilling and meaningful life, and they daughter because they now have a
Age: 65 Above will experience ego integrity. This is stable job and family on their own. The
characterized by a sense of acceptance of their patient has performed her role as a
life as it was, the ability to find coherence and parent and is now content.
purpose in their experiences, and a sense of
wisdom and fulfillment. On the other hand, if
individuals feel regretful about their past, feel
they have made poor decisions, or believe
they’ve failed to achieve their life goals, they
may experience despair.
B. JEAN PIAGET’S COGNITIVE DEVELOPMENT
STAGE BASIC ACTUAL

Formal Operation Stage In this stage, an individual can think about The patient is restless and is incoherent
(12 years and older) multiple variables in systematic ways,
formulate hypothesis, and consider
possibilities. They can also ponder
C. JAMES FOWLER’S STAGE OF FAITH
STAGE BASIC ACTUAL

Conventional Morality Characterized by an acceptance of social The patients consciousness is altered
rules concerning right and wrong. At the and the patient is restless.
(Maintaining the social order) conventional level, we begin to internalize the
moral standards of valued adult role models.
Authority is internalized but not questioned,
and reasoning is based on the norms of the
group to which the person belongs.
DEFINITION OF TERMS
Congestive heart failure- Inability of the heart to keep up with the demands on it, with failure of the
heart to pump blood with normal efficiency. When this occurs, the heart is unable to provide
adequate blood flow to other organs, such as the brain, liver, and kidneys.
Source: https://www.rxlist.com/congestive_heart_failure/definition.htm
Congestive heart failure (CHF)- occurs when the heart is unable to pump blood throughout the body
efficiently. Congestive heart failure (CHF) is a chronic progressive condition that affects the pumping
power of your heart muscle. While often referred to simply as heart failure, CHF specifically refers to
the stage in which fluid builds up within the heart and causes it to pump inefficiently.
Source: https://www.healthline.com/health/congestive-heart-failure
Congestive heart failure- is a condition in which the heart no longer pumps enough blood for the
body, causing fluid buildup around the heart, lungs and other tissues. People often use the terms
“CHF” and “heart failure” interchangeably. But CHF refers to the progressive stages of fluid buildup,
and heart failure refers to the heart’s inability to pump enough blood.
ETIOLOGY
PREDISPOSING
FACTOR RATIONALE ACTUAL JUSTIFICATION
Aging can weaken and stiffen your heart muscle. During aging,
deterioration in cardiac structure and function leads to increased
Age 60 years old above susceptibility to heart failure.
Women found to be at higher risk for heart failure and heart attack
death than men. Researchers found women face a 20% increased risk
of developing heart failure or dying within five years after their first
severe heart attack compared with men.
Gender
Inherited genetic mutations can affect the structure of the heart The patient
muscle, which can result in symptoms of heart failure. Gene state that they
mutations can also affect the heart's electrical system, which might have family
history of
Genes/ lead to abnormal heart rhythms.
heart disease
Hereditary on both sides.
Some people who develop heart failure are born with problems that The patient
affect the structure or function of their heart. If your heart and its was diagnosed
Congenital Heart chambers or valves haven't formed with Heart
failure on 2016
Diseases
correctly, the healthy parts of your heart have to work harder to
pump blood, which may lead to heart failure.
The disease results from the buildup of fatty deposits in the arteries,
which reduces blood flow and can lead to heart attack. Narrowed
Coronary Artery arteries may limit your heart's supply of oxygen-rich blood, resulting
in weakened heart muscle.
Disease/
Atherosclerosis
Coronary Artery
arteries may limit your heart's supply of oxygen-rich blood, resulting
Disease/
Atherosclerosis in weakened heart muscle.
The valves ensure that blood flows in one direction. With valvular
dysfunction, it becomes increasingly difficult for blood to move
Valvular Heart forward, increasing pressure within the heart and increasing cardiac
workload, leading to heart failure.
Disease
arteries may limit your heart's supply of oxygen-rich blood, resulting
Coronary Artery
in weakened heart muscle.
Disease/
Atherosclerosis
PREDISPOSING
FACTOR RATIONALE ACTUAL JUSTIFICATION
Smoking harms nearly every organ in the body, including the heart,
blood vessels, lungs, eyes, mouth, reproductive organs, bones,
bladder, and digestive organs. The chemicals you inhale when you
smoke cause damage to your heart and blood vessels that makes you
more likely to develop atherosclerosis, or plaque buildup in the
arteries which in time leads in CHF.
Smoking
Sustained hypertension eventually leads to changes that impair the
Hypertension heart’s ability to fill properly during diastole, and the hypertrophied
ventricles may dilate and fail.
Low SES is an important determinant of access to health care. The patient
Persons with low incomes are more likely to be Medic-aid recipients state that they
or uninsured, have poor quality health care, and seek health care less have family
history of
often; when they do seek health care, it is more likely to be for an
Low heart disease
emergency. on both sides.
Socioeconomic Status
When there is too much cholesterol in your blood, it builds up in the The patient
walls of your arteries, causing a process called atherosclerosis, a form was diagnosed
of heart disease. The arteries become narrowed and blood flow to with Heart
the heart muscle is slowed down or blocked causing more risk to failure on 2016
develop CHF.
High cholesterol
Obese individuals tend to have greater amounts of blood, which

makes the heart pump harder and can lead to heart failure over time.
Obesity is linked to sleep apnea, which causes lung problems as well
as high blood pressure, both of which can eventually lead to heart
failure.
Obesity
High blood sugar can damage blood vessels and the nerves that
control your heart. People with diabetes are also more likely to have
other conditions that raise the risk for heart disease including
hypertension and high cholesterol levels.
Diabetes
Long-term alcohol abuse weakens and thins the heart muscle,
Alcohol abuse affecting its ability to pump blood. When your
Illegal drug use heart can't pump blood efficiently; the lack of blood flow disrupts all
your body's major functions. This can lead to heart failure and other
life-threatening health problems.
ANATOMY AND PHYSIOLOGY

The Cardiovascular System
The cardiovascular system consists of the heart, blood vessels, and blood. Its primary function is to transport nutrients and oxygen-rich blood to all
parts of the body and to carry deoxygenated blood back to the lungs. The heart pumps blood through closed vessels to every tissue within the body. The
blood itself then delivers nutrients and oxygen to all cells in the body. Without blood, the cells and tissues would not function at their total capacity and
would begin to malfunction and die.
Structure of the Heart

The heart consists of four distinct chambers: two upper chambers called “atria” and two lower chambers called “ventricles.” A wall or “septum”
separates the atria and ventricles. Valves control the flow of blood within the different chambers.
Blood follows the following path through the heart:
• Blood lacking oxygen returns from the body and enters the right atrium (upper right chamber) via the inferior vena cava and superior vena cava veins.
• Blood flows through the tricuspid valve and enters the right ventricle (lower right chamber).
• The right ventricle pumps blood through the pulmonary valve and out of the heart via the main pulmonary artery.
• The blood then flows through the left and right pulmonary arteries into the lungs. Here, the process of breathing draws oxygen into the blood and
removes carbon dioxide. As a result, the blood is now rich in oxygen.
• The blood returns to the heart and flows into the left atrium (upper left chamber) via four pulmonary veins.
• Blood flows through the mitral valve and enters the left ventricle (lower left chamber).
• The left ventricle pumps the blood through the aortic valve into a large artery called the “aorta.” This artery delivers blood to the rest of the body.
SYMPTOMATOLOGY
BASIC SYMPTOMS RATIONALE ACTUAL
Dizziness If a stroke happens in the cerebellum or brainstem,

the areas that control balance in the brain, it may
cause vertigo. This means having a feeling that the
world around the person affected by it is moving or
spinning. He or She can feel dizzy or lose their
balance.
Headache, nausea, vomiting Due to the occurrence of the increase Intercranial
pressure which results to this symptom
Atrophy Due to irreversible damage to the right hemisphere

of the brain, normal neurotransmissions impaired
resulting to the decline of function of the brain
★
Slurring speech The cerebral cortex is affected which is part of the The patient cannot
brain where language, awareness and others are verbally
regulated.
communicate
Paralysis Because part of the brain is affected, particularly

the basal ganglia where all motor control and
activities are also regulated.
★
Hemiplegia Hemiplegia is paralysis that affects only one side of The Patient is
your body. This symptom is often a key indicator of
experiencing right
severe or life-threatening conditions like a stroke,
but can also happen with conditions and sided body weakness
circumstances that aren’t as dangerous.
due to her
Cerebrovascular
Infarction at the left
side of the Brain
★
Dysphagia Dysphagia affects more than 50% of stroke The patient has
survivors. Fortunately, the majority of these
difficulty in
patients recover swallowing function within 7 days,
and only 11-13% remain dysphagic after 6 months swallowing and is
using nasogastric
tube
PATHOPHYSIOLOGY
MEDICAL MANAGEMENT
LABORATORY RESULTS
PATIENT’S NAME: FELICILDA, ALICITA OLITA AGE: 73 MARITAL STATUS: MARRIED
DIAGNOSIS: CEREBROVASCULAR ACCIDENT
LABORATORY INDICATION REFERENCE ACTUAL SIGNIFICANCE NURSING CONSIDERATIONS
TEST VALUE FINDINGS THE FINDINGS
Computed  Detect brain Normal size, There I a Infarct of Impression: Pre-nursing consideration
Tomography, infection, position, and the left-  Infarct in the 1. Positively identify the patient using
Brain Plain abscess, or shape of frontotemporal left-fronto- at least two unique identifiers
 Computed necrosis, as intracranial area at temporal area before providing care, treatment, or
tomography evidenced by structures intermediate age. at intermediate services.
(CT) of the brain decreased and vascular There is a age. 2. Inform the patient that the test is
is a noninvasive density on system Microvascular  Microvascular used to evaluate numerous
procedure used the image changes in both Changes in conditions involving red blood cells,
to assist in  Detect periventricular both white blood cells, and platelets.
diagnosing ventricular white matter and periventricular 3. Ensure results of coagulation
abnormalities of enlargement there is a chronic white matter. testing are obtained and recorded
the head, brain or sinusitis in the left prior to the procedure; BUN and
tissue, displacement maxillary.  Cerebru- creatinine results are also needed
cerebrospinal by increased cerebellar loss if contrast medium is to be used
fluid, and blood cerebrospina compatible with 4. Explain that an IV line may be
circulation. l fluid age inserted to allow infusion of IV
fluids, contrast medium, dye, or
 Chronic left sedatives. Usually contrast
maxillary medium and normal saline are
sinusitis. infused.
5. Inform the patient that he or she
may experience nausea, a feeling
of warmth, a salty or metallic taste,
or a transient headache after
injection of contrast medium.

6. Instruct the patient to remove
dentures and jewelry and other
metallic objects from the area to be
examined.
Intra-nursing considerations
1. Ensure the patient has complied
with medication restrictions and
pretesting preparations.
2. Ensure the patient has removed
dentures and all external metallic
objects from the area to be
examined prior to the procedure.
3. Place the patient in the supine
position on an exam table.
4. If contrast media is used, a rapid
series of images is taken during
and after injection.
5. Instruct the patient to take slow,
deep breaths if nausea occurs
during the procedure.
6. The needle is removed, and a
pressure dressing is applied over
the puncture site.
7. Observe the needle insertion site
for bleeding, inflammation, or
hematoma formation.
Post-nursing consideration
1. A report of the results will be sent
to the requesting HCP, who will
discuss the results with the
patient.
2. Instruct the patient to resume
medications and activity, as

directed by the HCP.
3. Monitor vital signs and neurologic
status every 15 min for 1 hr, then
every 2 hr for 4 hr, and then as
ordered by the HCP. Monitor
temperature every 4 hr for 24 hr.
Compare with baseline values.
Notify the HCP if temperature is
elevated. Protocols may vary
from facility to facility
4. If contrast was used, advise the
patient to immediately report
symptoms such as fast heart rate,
difficulty breathing, skin rash,
itching, or decreased urinary
output.
5. Observe the needle insertion site
for bleeding, inflammation, or
hematoma formation.
6. Instruct the patient to apply cold
compresses to the puncture site
as needed, to reduce discomfort
or edema.
7. Instruct the patient to increase
fluid intake to help eliminate the
contrast medium, if used.
8. Inform the patient that diarrhea
may occur after ingestion of oral
contrast medium.
MEDICAL MANAGEMENT
LABORATORY RESULTS
LABORATORY INDICATION REFERENCE VALUE ACTUAL SIGNIFICANCE NURSING CONSIDERATIONS
TEST FINDINGS THE FINDINGS
Complete Blood Provide WBC (4.50-10.50 10^9/L) 6.26 Patient has Pre-nursing consideration
Count screening as RBC (4.00-6.00 10^12/L) 3.95 decreased
Positively identify the patient using at least two
 A complete part of a Hematocrit (35.00-49%) 31.6 lymphocyteunique
and identifiers before providing care,
blood count general Hemoglobin (12.00-15.00 11.3 neutrophiltreatment,
and or services.
(CBC) is a group physical a/dL) low hemoglobin
Inform the patient that the test is used to
of tests used for examination, MCV (8-.00-100.00 FL) 80.0 evaluate numerous conditions involving red
basic screening especially on MCH (27.00-34.00 pg) 28.7 blood cells, white blood cells, and platelets.
purposes. It is admission to MCHC (31.00-37.00 g/dl) 35.9 Review the procedure with the patient. Inform
probably the a health care Neutrophil (50.00- 81.4 the patient that specimen collection takes
most widely facility or 70.00%) approximately 5 to 10 min. Address concerns
ordered before Lymphocyte (20.00- 14.9 about pain and explain that there may be some
laboratory test. surgery. 40.00%) discomfort during the venipuncture.
Results provide Intra-nursing considerations
the enumeration 1. Instruct the patient to cooperate
of the cellular fully and to follow directions.
elements of the Direct the patient to breathe
blood, normally and to avoid
measurement of unnecessary movement.
RBC indices, 2. Observe standard precautions,
and and follow the general guidelines.
determination of 3. Positively identify the patient, and
cell morphology label the appropriate tubes with
by automation the corresponding patient
and evaluation of demographics, date, and time of
stained smears. collection. Perform a

venipuncture.
4. Remove the needle and apply
direct pressure with dry gauze to
stop bleeding. Observe
venipuncture site for bleeding or
hematoma formation and secure
gauze with adhesive bandage.
5. Promptly transport the specimen
to the laboratory for processing
and analysis.
Post-nursing consideration
1. A report of the results will be sent
to the requesting HCP, who will
patient.
2. Reinforce information given by
the patient’s HCP regarding
further testing, treatment, or
referral to another HCP. Answer
any questions or address any
concerns voiced by the patient or
family
MEDICAL MANAGEMENT
LABORATORY RESULTS
LABORATORY INDICATION REFERENCE VALUE ACTUAL SIGNIFICANCE NURSING CONSIDERATIONS
TEST FINDINGS THE FINDINGS
Electrolytes test Performed a as part Sodium (Na) [135.0-148.mmol/L] 133 The patient’ level od Pre-nursing considerations
- Electrolytes test of a routine Potassium (K) [3.50-5.30 mmol/L] 3.81 Creatinnine is high 1. Positively identify the patient
is a diagnostic examination or Chloride (Cl) [98.0-107.0 mmol/L] 105.1 using at least two unique
test that helps in sometimes as a part Calcium (Cl) [1.13-1.32 mmol/L] 1.2 identifiers before providing
determining the of a more Creatinine (0.7-1.4 mg/dL 4.90 care, treatment, or services.
levels of comprehensive [Female]) 2. Inform the patient that the test
electrolytes (salts testing procedure. HCO3 (22-26 mmol/L) 14.8 is used to assist in the
and minerals) in PO2 (83-105mmHg) 114.0 evaluation of electrolyte
the blood. PCO2 (35.45mmHg 26.1 balance.
Intra-nursing procedure
1. Instruct the patient to
cooperate fully and to follow
directions. Direct the patient
to breathe normally and to
avoid unnecessary
movement.
2. Observe standard
precautions, and follow the
general guidelines.
3. Positively identify the patient,

and label the appropriate
tubes with the corresponding
patient demographics, date,
and time of collection.

Perform a venipuncture.
4. Remove the needle and apply
direct pressure with dry gauze
to stop bleeding. Observe
venipuncture site for bleeding
and hematoma formation and
secure gauze with adhesive
bandage.
5. Promptly transport the
specimen to the laboratory for
processing and analysis.
Post-nursing considerations
1. A report of the results will be
sent to the requesting health
care provider (HCP), who will
patient.
2. Reinforce information given
by the patient’s HCP
regarding further testing,
treatment, or referral to
another HCP. Answer any
questions or address any
concerns voiced by the
patient or family
MEDICAL MANAGEMENT
DRUG STUDY
PATIENT’S NAME: FELICILDA, A. AGE: 73 MARITAL STATUS: MARRIED
SIDE
MODE OF
DRUG NAME INDICATIONS CONTRAINDICATIONS EFFECTS/ADVERSE NURSING INTERVENTIONS
ACTION
EFFECTS
Generic Name: Acts on Pulmonary Anuria, hypovolemia CNS: Headache,  Observe the 10 right drug
Furosemide the edema, edema fatigue, weakness, administration
ascending in CHF, vertigo, paresthesias  Assess for any
Brand Name: loop of Nephrotic CV: Orthostatic hypersensitivity reaction
Lasix Henle in syndrome, hypotension, chest  Assess for any adverse
the ascites, hepatic pain, ECG effects
Therapeutic kidney, disease, changes, circulatory  Monitor for CV, GI,
Class: Loop inhibiting hypertension collapse neurologic
diuretic reabsorption EENT: Loss of manifestations of
of hearing, ear pain, hyponatremia:
Pharmacological electrolytes tinnitus, blurred increased B/P, cold,
Class: sodium vision clammy skin,
Sulfonamide and ELECT: Hypokalemia, hypovolemia or
derivative chloride, hypochloremic hypervolemia; anorexia,
causing alkalosis, nausea, vomiting, diarrhea,
Actual Dose, excretion hypomagnesemia, abdominal cramps;
Timing and Route: of hyperuricemia, hy- lethargy, increased ICP,
40mg/tab, 1 tab 3x sodium, pocalcemia, confusion, headache,
a week calcium, hyponatremia, seizures, coma, fatigue,
magnesium, metabolic alkalosis tremors, hyperreflexia
chloride, ENDO: Hyperglycemia  Monitor for neurologic,
water, GI: Nausea, respiratory

and some diarrhea, dry manifestations of
potassium; mouth, vomiting, hyperchloremia: weakness,
decreases anorexia, cramps, lethargy, coma; deep
reabsorption oral or gastric rapid breathing
of irritations,  Monitor signs of allergic
sodium and pancreatitis reactions and anaphylaxis,
chloride GU: Polyuria, renal including pulmonary
and failure, glycosuria, symptoms (tightness in the
increases bladder spasms throat and chest, wheezing,
excretion HEMA: cough dyspnea) or skin
of Thrombocytopenia, reactions (rash, pruritus,
potassium agranulocyto- urticaria). Notify physician
in the sis, leukopenia, or nursing staff immediately
distal neutropenia, anemia if these reactions occur.
tubule of INTEG: Rash, pruritus,  Teach patient to take the
the kidney; purpura, Stevens- medication early in the
responsible Johnson syndrome, day to prevent nocturia
for slight sweating,  Instruct the patient to take
antihypertens photosensitivity, with food or milk if GI
ive effect urticaria symptoms of nausea and
and MS: Cramps, stiffness anorexia occur
peripheral SYST: Toxic epidermal  Teach patient to maintain
vasodilatation necrolysis a record of weight on a
weekly basis and notify
physician of weight loss
of .5 lb
 Caution the patient that
this product causes a loss
of potassium, that food
rich in potassium should be
added to the diet; refer to
a dietitian for assistance
in planning
MEDICAL MANAGEMENT
DRUG STUDY
SIDE
MODE OF
ACTION
EFFECTS
Generic Name: Inhibits Reducing the Hypersensitivity, CNS: Headache,  Assess for symptoms of
Clopidogrel first and risk of stroke, active bleeding dizziness, stroke, MI during treatment
second MI, depression,  Assess for
Brand Name: phases vascular death, syncope, thrombotic/thrombocytic
Plavix of ADP- peripheral hyperesthesia, purpura; fever,
induced arterial disease neuralgia, confusion, thrombocytopenia,
Therapeutic effects in in hallucinations neurolytic anemia
Class: Platelet platelet high-risk CV: Edema,  Monitor liver function tests:
aggregation aggregation patients, acute hypertension, chest AST, ALT, bilirubin,
inhibitor coronary pain creatinine if patient is on
syndrome, GI: Nausea, long-term therapy(4 mo or
Pharmacological transient vomiting, diarrhea, GI more)
Class: ischemic attack discomfort, GI  Monitor blood studies:
Thienopyridine (TIA), unstable bleeding, pancreatitis, CBC, Hct, Hgb, protime,
derivative angina hepatic failure cholesterol if patient is on
GU: long-term therapy;
Actual Dose, Glomerulonephritis thrombocytopenia,
Timing and Route: HEMA: Epistaxis, neutropenia may occur
75mg/tab, 1 tab purpura, bleeding weakness, lethargy,
OD DC lunch (major/minor from any coma; deep rapid breathing
site), neutropenia,  Advise patient that blood
aplastic anemia, work will be necessary

agranulocytosis, during treatment
thrombotic  Advise patient to
thrombocytopenic report any unusual
purpura bleeding to prescriber,
INTEG: Rash, that it may take
pruritus longer to stop bleeding
MISC: UTI,  Teach patient to
hypercholesterolemia, take without regard
chest pain, to food
fatigue, intracranial  Caution patient to
hemorrhage, toxic report diarrhea, skin
epidermal necrolysis, rashes, subcutaneous
Stevens-Johnson bleeding, chills, fever,
syndrome, flu-like sore throat
syndrome,
anaphylaxis
MS: Arthralgia, back
pain
RESP: Upper
respiratory tract
infection, dyspnea,
rhinitis, bronchitis,
cough, bronchospasm
MEDICAL MANAGEMENT
DRUG STUDY
SIDE
MODE OF
ACTION
EFFECTS
Generic Name: Inhibits As an adjunct Pregnancy X, CNS: Headache,  Assess diet: obtain diet
Rosuvastatin HMG-CoA in primary breastfeeding, dizziness, insomnia, history including fat,
reductase, hypercholesterolemi hypersensitivity, paresthesia, confusion cholesterol in diet
Brand Name: which a (types IIa, IIb), active liver disease GI: Nausea,  Monitor fasting
Roswin reduces mixed constipation, cholesterol, LDL, HDL,
cholesterol dyslipidemia abdominal pain, flatus, triglycerides periodically
Therapeutic synthesis Elevated serum diarrhea, dyspepsia, during treatment
Class: Antilipemic triglycerides, heartburn, kidney  Liver function: monitor
homozygous/hetero failure, liver liver function tests
Pharmacological zygous familial dysfunction, vomiting  q1-2mo during the first
Class: HMG-CoA hypercholesterolemi HEMA: 1½ yr oftreatment; AST,
reductase a(FH), slowing Thrombocytopenia, ALT, liver function tests
inhibitor of hemolytic anemia, may increase
atherosclerosis, leukopenia  Monitor renal function in
Actual Dose, CV disease INTEG: Rash, pruritus patients with
Timing and Route: prophylaxis, MI, MS: Asthenia, muscle compromised renal
200mg/tab, 1 tab stroke cramps, arthritis, system: BUN, creatinine,
OD HS prophylaxis arthralgia, myalgia, I&O ratio
(normal LDL) myositis,  Obtain ophthalmic exam
rhabdomyolysis, before, 1mo after
leg, shoulder, or treatment begins,
localized pain annually; lens opacities

RESP: Rhinitis, may occur
sinusitis,  Advise that blood work
pharyngitis, and ophthalmic exam will
increased cough be necessary during
treatment
 Teach to report blurred
vision, severe GI
symptoms, dizziness,
headache, muscle pain,
weakness
MEDICAL MANAGEMENT
DRUG STUDY
SIDE
MODE OF
ACTION
EFFECTS
Generic Name: Blocks Hypertension, Hypersensitivity, CNS: Dizziness,  Assess B/P (lying, sitting,
Valsartan the alone or in severe hepatic insomnia, standing), pulse q4hr;
vasoconstrict combination, in disease, bilateral drowsiness, note rate, rhythm, quality
Brand Name: or and patients .6 yr; renal artery stenosis vertigo, headache, periodically
Valazyd aldosterone- CHF, after MI fatigue  Monitor electrolytes:
secreting with left CV: Angina pectoris, potassium, sodium,
Therapeutic effects of ventricular 2nd-degree AV chloride; total CO2
Class: angiotensin dysfunction/failure block, cerebrovascular  Assess for angioedema:
Antihypertensive II; in stable patients accident, facial swelling, shortness
selectively hypotension, MI, of breath
Pharmacological blocks dysrhythmias  Obtain baselines in
Class: the EENT: Conjunctivitis renal, liver function
AngiotensinII binding of GI: Diarrhea, tests before therapy
receptor angiotensin abdominal pain, begins
antagonist(type II to nausea, hepatotoxicity  Assess blood tests:
AT1) the AT1 GU: Impotence, BUN, creatinine, before
Actual Dose, receptor nephrotoxicity, renal treatment
Timing and Route: found in failure  Monitor for edema in
80mg/tab, 1 tab tissues HEMA: Anemia, feet, legs daily
OD neutropenia  Assess for skin turgor,

META: Hyperkalemia dryness of mucous
MISC: Vasculitis, membranes for hydration
angioedema status; correct volume
MS: Cramps, depletion before initiating
myalgia, pain, therapy
stiffness  Overdose symptoms:
RESP: Cough bradycardia or
tachycardia, circulatory
collapse
MEDICAL MANAGEMENT
NURSING CARE PLAN
PATIENT’S NAME: FELICILDA, ALICIA OLITA AGE: 73 MARITAL STATUS: MARRIED
NURSING
NSG. GOAL & NURSING
CUES/DATA DIAGNOSI RATIONALE EVALUATION
OBJECTIVES INTERVENTIONS
S
Subjective Data: Decreased After 8 hours of nursing 1. Introduce self and 1. To facilitate patient’s After 8 hours of
interventions, the patient nursing
“Mubo man ko cardiac maintain rapport. cooperation.
will be able to interventions, the
ug BP”
output demonstrate adequate 2. Take vital signs and 2. For baseline data. goal was met as
as verbalized by cardiac output as record. evidenced by
related to 3. Decreases the extracellular
the patient. evidenced by blood 3. For patient with patient
impaired pressure and pulse rate fluid volume and reduces demonstrated
increased preload, limit
and rhythm within demands on the heart. adequate cardiac
contractility
Objective Data: normal parameters for fluids and sodium as output as
patient 4. In patients with decreased evidenced by blood
• Tachypnea ordered.
cardiac output, poorly pressure and pulse
• Shortness of 4. Closely monitor fluid rate and rhythm
breath functioning ventricles may not within normal
intake, including IV lines.
tolerate increased fluid parameters for
• Hypotension Maintain fluid restriction patient
• Vital signs as volumes.
if ordered.
follows: 5. Atrial fibrillation is common in
5. Place on a cardiac
heart failure and can cause a
• T: 36.7°C monitor; monitor for thromboembolic event

dysrhythmias, especially
• P: 113 bpm
atrial fibrillation.
• R: 26 cpm 6. This promotes the cooperation of
• BP: 90/60 the patient in their own medical
mmHg
6. Observe patient for situation.
• SpO2: 84%
understanding and 7. To reduce preload and ventricular
compliance with medical filling when fluid overload is the
regimen, including cause.
medications, activity 8. The failing heart may not
level, and diet. be able to respond to increased
7. Position patient in semi- oxygen demands. Oxygen
Fowler’s to high-Fowler. saturation needs to be greater
8. Administer oxygen than 90%.
therapy as prescribed. 9 In severe heart failure, restriction
of activity often facilitates
9. During acute events,
temporary recompensation
ensure the patient
remains on bed rest or
10. The nurse must assess how well
maintains an activity
level that does not the patient tolerates current
compromise cardiac
medications before
output.
10. Monitor blood pressure, administering cardiac
pulse, and condition medications; do not hold
before administering medications without physician
cardiac medications such input. The physician may decide

as angiotensin to have medications
converting enzyme (ACE) administered even though the
inhibitors, digoxin, and blood pressure or pulse rate has
betablockers such as lowered.
carvedilol. Notify the
physician if heart rate or
blood pressure is low
before holding
medications.
MEDICAL MANAGEMENT
NURSING CARE PLAN
NURSING NSG. GOAL & NURSING
CUES/DATA RATIONALE EVALUATION
DIAGNOSIS OBJECTIVES INTERVENTIONS
SUBJECTIVE Activity At the end of the 1. Assess the physical 1. Provides baseline After the nursing
DATA: intolerance nursing activity level and information for Interventions the
“di lage kaajo na related to Interventions the mobility of the patient. formulating nursing patient was able to
sija kalihok generalized patient will: goals during goal prescribed physical
maam, na weakness  prescribed setting. activity with
paralyze lage na physical 2. Assess the appropriate
ijang right side activity with patient’s nutritional 2. Adequate energy changes in heart
maam” as stated appropriate status. reserves are needed rate, blood
by the patient’s changes in during activity. pressure, and
SO heart rate, 3. Observe and monitor respiratory rate.
blood the 3. Sleep deprivation and The patient was
OBJECTIVE pressure, and patient’s sleep pattern difficulties during sleep able to verbalize an
DATA: respiratory and the amount can affect the activity understanding of
Patient keeps rate. of sleep achieved over level of the patient the need to
lying in bed most  verbalize an the past few days. gradually increase
of the time. understanding 4. May determine the use activity based on
Non-ambulatory of the need to 4. Use portable pulse of supplemental oxygen tolerance. And the
gradually oximetry to assess for to help compensate for Goals where meet.
VS: increase oxygen desaturation the increased oxygen
T: 35.4 activity based during activity. demands during
P: 67bpm on tolerance. physical activity.
R: 21cpm
BP:
140/80mmHg 5. Depression over
5. Assess emotional the inability to perform

response to limitations activities can be a
in physical activity. source of stress and
frustration.
6. Motivation and
6. Establish guidelines cooperation are
and goals of activity enhanced if the patient
with the patient and/or participates in goal
SO. setting.
7. Prevents
7. Dangle the legs from orthostatic hypotension.
the bed side for 10 to
15 minutes.
8. Patient with limited
8. Refrain from activity tolerance need
performing to prioritize important
nonessential activities task first.
or procedures.
9. Assisting the patient

9. Assist with ADLs while with ADLs allows
avoiding patient conservation of energy.
dependency.
10. This helps the patient
10. Encourage to cope.
verbalization of Acknowledgment that
feelings regarding living with activity
limitations. intolerance is both
physically and
emotionally difficult.
MEDICAL MANAGEMENT
NURSING CARE PLAN
NURSING NSG. GOAL &
CUES/DATA NURSING INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS OBJECTIVES
SUBJECTIVE Self-care deficit At the end of 1. Assess abilities and level 1. Aids in planning for At the end of
DATA: “Ako related to nursing of deficit (0–4 scale) for meeting individual needs. nursing
nalaman lage decreased interventions, performing ADLs. intervention,
mag atiman ni strength and the patient will: the patient was
mama maam endurance demonstrate 2. This Promotes the able to perform
pero lisud lage techniques/lifest 2. Take the patient to the patient’s independent self-care
kay wa pakoy yle changes to bathroom at control of this function as activities and
kauban” as meet self-care periodic intervals for recovery progresses. thus the goals
verbalized by the needs. voiding if appropriate. where meet
SO perform self-
care activities
OBJECTIVE within level of 3. Identify previous bowel 3. Assists in developing a
DATA: own ability. habits and reestablish a retraining program and
Dry lips noted normal regimen. aids in preventing
Poor oral hygiene constipation and
VS: impaction.
VS:
T: 35.4
P: 67bpm 4. Avoid doing things for the 4. To maintain self-esteem
R: 21cpm patient that patient can do and promote recovery,
BP: 140/80mmHg for themself, but assist as the patient needs to do as
necessary. much as possible for
themself.
5. Be aware of impulsive 5. May indicate the need for

actions suggestive of additional interventions
impaired judgment. and supervision to
promote patient safety.
6. Allow the patient 6. Patients need empathy

sufficient time to and to know caregivers
accomplish tasks. Don’t will be consistent in their
rush the patient. assistance.
7. Provide positive feedback 7. Enhances sense of self-

for efforts and worth, promotes
accomplishments. independence, and
encourages the patient to
continue endeavors.
8. Reestablishes a sense of
8. Encourage SO to allow independence and fosters
the patient to do self-care self-worth, and enhances
as much as possible. the rehabilitation
process.
9. Teach the patient to 9. To promote a sense of

comb hair, dress, and independence and self-
wash. esteem.
10. Be aware of impulsive 10. May indicate the need for

actions suggestive of additional interventions
impaired judgment and supervision to
promote patient safety.
MEDICAL MANAGEMENT
NURSING CARE PLAN
NURSING NSG. GOAL &
CUES/DATA NURSING INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS OBJECTIVES
SUBJECTIVE Risk for  At the end of 1. Review individual pathology 1. Assess the patient’s ability to The patient
DATA: Impaired nursing and ability to swallow, noting swallow as soon as possible was able to eat
“Bitaron lage na Swallowing Interventions, the extent of the paralysis: and before any oral intake. her prepared
nija ijang NGT the patient clarity of speech, tongue Nutritional interventions and foods without
ug oxygen will involvement, ability to protect choices of feeding routes are aspiration. The
maam” as demonstrate the airway, episodes of determined by these factors. goals are meet.
verbalized by feeding coughing, presence of
the SO methods adventitious breath sounds.
appropriate
to individual 2. Maintain accurate I&O; record 2. Alternative feeding methods
OBJECTIVE situation with calorie count. may be used if swallowing
DATA: aspiration efforts are not sufficient to
Restlessness prevented. meet fluid and nutritional
Irritable needs.
behavior
Facial 3. Have suction equipment
grimmace available at the bedside, 3. Timely intervention may limit
especially during early feeding the untoward effects of
VS: efforts. aspiration.
T: 35.4
P: 67bpm 4. Promote effective swallowing:
R: 21cpm Schedule activities and 4. Promotes optimal muscle
BP: medications to provide a function, helps to limit fatigue.
140/80mmHg minimum of 30 min rest before
eating.
5. Provide a pleasant and
unhurried environment free of 5. Promotes relaxation and
distractions. allows the patient to focus on
the task of eating.
6. Assist patient with head control

and position based on specific
dysfunction.
6. Counteracts hyperextension,
aiding in the prevention of
aspiration and enhancing the
7. Place the patient in an upright ability to swallow.
position during and after
feeding as appropriate.
7. To reduce the risk of aspiration
8. Provide oral care based on by use of gravity to facilitate
individual needs before a meal. swallowing.
8. Patients with dry mouth require

moisturizing agents like
9. Feed slowly, allowing 30–45 alcohol-free mouthwashes
min for meals. before and after eating.
9. Increases salivation, improving

bolus formation and
10. Encourage participation in an swallowing effort.
exercise program.
10. May increase release of
endorphins in the brain,
promoting a sense of general
well-being and increasing
appetite.
JOURNAL READING
Ischemic Stroke in a 29-Year-Old Patient with COVID-19: A Case Report
By: Christian Avvantaggiato Case Rep Neurol 2021; 13:334–340
Source: https://doi.org/10.1159/000515457
Abstract
Increasing evidence reports a greater incidence of stroke among patients with Coronavirus
disease 2019 (COVID-19) than the non-COVID-19 population and suggests that SARS-CoV-
2 infection represents a risk factor for thromboembolic and acute ischemic stroke. Elderly
people have higher risk factors associated with acute ischemic stroke or embolization
vascular events, and advanced age is strongly associated with severe COVID-19 and death.
We reported, instead, a case of an ischemic stroke in a young woman during her
hospitalization for COVID-19-related pneumonia. A 29-year-old woman presented to the
emergency department of our institution with progressive respiratory distress associated with
a 2-day history of fever, nausea, and vomiting. The patient was transferred to the intensive
care unit (ICU) where she underwent a tracheostomy for mechanical ventilation due to her
severe clinical condition and her very low arterial partial pressure of oxygen. The
nasopharyngeal swab test confirmed SARS-CoV-2 infection. Laboratory tests showed
neutrophilic leucocytosis, a prolonged prothrombin time, and elevated D-dimer and
fibrinogen levels. After 18 days, during her stay in the ICU after suspension of the
medications used for sedation, left hemiplegia was reported. Central facial palsy on the left
side, dysarthria, and facial drop were present, with complete paralysis of the ipsilateral upper
and lower limbs. Computed tomography (CT) of the head and magnetic resonance imaging
of the brain confirmed the presence of lesions in the right hemisphere affecting the territories
of the anterior and middle cerebral arteries, consistent with ischemic stroke. Pulmonary and
splenic infarcts were also found after CT of the chest. The age of the patient and the
absence of serious concomitant cardiovascular diseases place the emphasis on the capacity
of SARS-CoV-2 infection to be an independent cerebrovascular risk factor. Increased levels
of D-dimer and positivity to β2-glycoprotein antibodies could confirm the theory of endothelial
activation and hypercoagulability, but other mechanisms – still under discussion – should not
be excluded.
© 2021 The Author(s). Published by S. Karger AG, Basel
Background
Coronavirus disease 2019 (COVID-19), caused by the novel coronavirus SARS-CoV-2, is
characterized by a wide range of symptoms, most of which cause acute respiratory distress
syndrome [1, 2], associated with intensive care unit (ICU) admission and high mortality [3].
On March 11, 2020, the large global outbreak of the disease led the World Health
Organization (WHO) to declare COVID-19 a pandemic, with 11,874,226 confirmed cases
and 545,481 deaths worldwide (July 9, 2020) [4]. In many cases, the clinical manifestations
of COVID-19 are characteristic of a mild disease that may, however, worsen to a critical
lower respiratory infection [2]. At the onset of the disease, the most frequent symptoms are
fever, dry cough, fatigue, and shortness of breath as the infection progresses may appear
signs and symptoms of respiratory failure that require ICU admission [5, 6]. Although acute
respiratory distress syndrome is the most important cause of ICU admission for COVID-19
patients, several studies have underlined the presence of neurological symptoms such as
confusion, dizziness, impaired consciousness, ataxia, seizure, anosmia, ageusia, vision
impairment, and stroke [7, 8]. In particular, the state of hypercoagulability in patients affected
by COVID-19 favors the formation of small and/or large blood clots in multiple organs,
including the brain, potentially leading to cerebrovascular disease (ischemic stroke but also
intracranial hemorrhage) [9, 10].
We found an interesting case of stroke following a SARS-CoV-2 infection in a young patient.
A 29-year-old woman, during her ICU hospitalization for COVID-19-related pneumonia, was
diagnosed with ischemic stroke of the right hemisphere, without other
cardiac/cerebrovascular risk factors except hypertension. The young age of the patient and
the absence of higher cerebrovascular risk factors make the present case very interesting as
it can help demonstrate that COVID-19 is an independent risk factor for acute ischemic
stroke. In a case series of 214 patients with COVID-19 (mean [SD] age, 52.7 [15.5] years),
neurologic symptoms were more common in patients with severe infection who were older
than the others [11]. New-onset CVD was more common in COVID-19 patients who had
underlying cerebrovascular risk factors, such as older age (>65 years) [12], and very few
cases of stroke in patients younger than 50 years have been reported [12, 13]. Our case
seems to be the only one younger than 30 years.
Case Presentation
On the night between March 19 and 20, 2020, a 29-year-old woman was referred to our
hospital “Policlinico Riuniti di Foggia” due to a progressive respiratory distress associated
with a 2-day history of fever, nausea, and vomiting. At presentation, the heart rate was 128
bpm, the blood oxygen saturation measured by means of the pulse oximeter was 27%, the
respiratory rate was 27 breaths per minute, and the blood pressure was 116/77 mm Hg. The
arterial blood gas test showed a pH of 7.52, pO2 20 mm Hg, and pCO2 34 mm Hg. The
patient was immediately transferred to the ICU where she underwent tracheostomy and
endotracheal intubation for mechanical ventilation due to her severe clinical condition and
deteriorated pulmonary gas exchange. The diagnosis of COVID-19 was confirmed by PCR
on a nasopharyngeal swab.
The family medical history was normal, and the only known pre-existing medical conditions
were polycystic ovary syndrome (diagnosed 3 years earlier), conversion disorder, and
hypertension (both diagnosed 2 years earlier). Ramipril and nebivolol were prescribed for the
high blood pressure treatment, and sertraline was prescribed for the conversion disorder
treatment. Drug therapy adherence was inconstant. The patient had no history of diabetes,
cardiac pathologies, strokes, transient ischemic attacks, thromboembolic, or other vascular
pathologies.
Laboratory tests showed neutrophilic leukocytosis (white blood cell count 14.79 × 103,
neutrophil percentage 89.8%, and neutrophil count 13.29 × 103), a prolonged prothrombin
time (15.3 s) with a slightly elevated international normalized ratio (1.38), and elevated D-
dimer (6,912 ng/mL) and fibrinogen levels (766 mg/dL). Other findings are shown in Table 1.
Table 1.
Laboratory test
This pharmacological therapy was set as follows: enoxaparin 6,000 U.I. once a day,
piperacillin 4 g/tazobactam 0.5 g twice a day; Kaletra, a combination of lopinavir and ritonavir
indicated for human immunodeficiency virus (HIV) infection treatment, 2 tablets twice a day;
hydroxychloroquine 200 mg once a day; and furosemide 250 mg, calcium gluconate, and
aminophylline 240 mg 3 times a day. No adverse events were reported.
On April 7, 2020, during her stay in the ICU and after suspension of the medications used for
sedation, left hemiplegia was reported. The same day, the patient underwent a computed
tomography examination of the head, which showed areas of hypodensity in the right
hemisphere due to recent cerebral ischemia.
On April 16, 2020, the patient was oriented to time, place, and person. Central facial palsy
on the left side, dysarthria, and facial drop were present, with complete paralysis of the
ipsilateral upper and lower limbs. The power of all the muscles of the left limbs was grade 0
according to the Medical Research Council (MRC) scale. Deep tendon reflexes were
reduced on the left upper limb but hyperactive on the ipsilateral lower limb, with a slight
increase in the muscle tonus. The senses of touch, vibration, and pain were reduced on the
left side of the face and body.
On the same day, the patient underwent magnetic resonance imaging (MRI) of the brain
(Fig. 1a), showing lesions on the right hemisphere affecting the territories of the anterior and
middle cerebral arteries. On May 5, 2020, magnetic resonance angiography showed an early
duplication of the sphenoidal segment of the right middle cerebral artery, the branches of
which are irregular with rosary bead-like aspects (Fig. 1d, e); on the same day, the second
MRI (Fig. 1b) confirmed the lesions. Computed tomography of the chest (Fig. 1c) and
abdomen (Fig. 1f), performed 5 days after the MRI of the brain, showed not only multifocal
bilateral ground-glass opacities but also a basal subpleural area of increased density within
the left lung (4 × 4 × 3 cm), consistent with a pulmonary infarction. In addition, a vascular
lesion, consistent with a splenic infarct, was found in the inferior pole of the spleen. Doppler
echocardiography of the hearth showed regular right chambers and left atrium and a slightly
hypertrophic left ventricle with normal size and kinetics (ejection fraction: 55%). The age of
the patient and the absence of serious concomitant cardiovascular diseases place the
emphasis on the capacity of SARS-CoV-2 infection to be an independent cerebrovascular
risk factor.
Fig. 1.
Imaging. a April 16, 2020; MRI of the brain: lesions in the right hemisphere affecting the
territories of the anterior and the middle cerebral arteries. b May 5, 2020; MRI of the brain:
same lesions in the right hemisphere shown in the previous image. d, e May 5, 2020; MRA
showed an early duplication of the sphenoidal segment of the right middle cerebral artery,
the branches of which are irregular with rosary bead-like aspect and reduction of blood flow
in the middle cerebral artery. c April 20, 2020; CT of the abdomen: vascular lesion,
consistent with a splenic infarct, found in the inferior pole of the spleen. f April 20, 2020; CT
of the chest: basal subpleural area of increased density within the left lung (4 × 4 × 3 cm),
consistent with a pulmonary infarction. MRA, magnetic resonance angiography; CT,
computed tomography; MRI, magnetic resonance imaging.
Discussion
The pandemic outbreak of novel SARS-CoV-2 infection has caused great concern among
the services and authorities responsible for public health due to not only the mortality rate
but also the danger of filling up hospital capacities in terms of ICU beds and acute non-ICU
beds. In this regard, the nonrespiratory complications of COVID-19 should also be taken into
great consideration, especially those that threaten patients’ lives and extend hospitalization
times. Stroke is one of these complications, since a greater incidence of stroke among
patients with COVID-19 than the non-COVID-19 population has been reported, and a
preliminary case-control study demonstrated that SARS-CoV-2 infection represents a risk
factor for acute ischemic stroke [14].
We found that the reported case is extremely interesting, since the woman is only 29 years
old and considering how stroke in a young patient without other known risk factors is
uncommon. Not only elderly people have higher risk factors associated with acute ischemic
stroke or embolization vascular events [15], but it is also true that advanced age is strongly
associated with severe COVID-19 and death. The severity of the disease is directly linked to
immune dysregulation, cytokine storm, and acute inflammation state, which in turn are more
common in patients who present immunosenescence [6].
Inflammation plays an important role in the occurrence of cardiovascular and
cerebrovascular diseases since it favors atherosclerosis and affects plaque stability [16]. The
ischemic stroke of the 29-year-old woman does not appear to be imputable to emboli
originating a pre-existing atheromatous plaque, both for the age of the patient and for the
absence of plaques at the Doppler ultrasound study of the supra-aortic trunks.
Most likely, COVID-19-associated hypercoagulability and endothelial dysfunction are the
causes of ischemic stroke, as suggested by other studies and case reports [10, 13, 17].
Although the mechanisms by which SARS-CoV-2 infection leads to hypercoagulability are
still being studied, current knowledge suggests that cross talk between inflammation and
thrombosis has a crucial role [18]. The release of inflammatory cytokines leads to the
activation of epithelial cells, monocytes, and macrophages. Direct infection of endothelial
cells through the ACE2 receptor also leads to endothelial activation and dysfunction,
expression of tissue factor, and platelet activation and increased levels of VWF and FVIII, all
of which contribute to thrombin generation and fibrin clot formation [17]. The 29-year-old
patient showed an increased level of D-dimer, which is a degradation product of cross-linked
fibrin, indicating a global activation of hemostasis and fibrinolysis and conforming to the
hypothesis of COVID-19-associated hypercoagulability. Endothelial activation and
hypercoagulability are also confirmed by positivity to β2 glycoprotein antibodies.
Anticardiolipin antibody and/or β2 glycoprotein antibody positivity has been reported in a few
studies [17, 19, 20]. In addition, widespread thrombosis in SARS-CoV-2 infection could also
be caused by neutrophil extracellular traps (NETs). Neutrophilia [21] and an elevated
neutrophil-lymphocyte ratio [22] have been reported by numerous studies as predictive of
worse disease outcomes, and recently, the contribution of NETs in the pathophysiology of
COVID-19 was reported [23]. Thrombogenic involvement of NETs has been described in
various settings of thrombosis, including stroke, myocardial infarction, and deep vein
thrombosis [24]. The high neutrophil count found in our case does not exclude the
hypothesis that NETs are involved in the pathogenesis of ischemic stroke.
Conclusion
Ischemic stroke in young patients without pre-existing cerebrovascular risk factors is very
unusual. In this regard, our case of an ischemic stroke, reported in a 29-year-old woman, is
very interesting. Although it is not possible to determine precisely when the thromboembolic
event occurred, our case of stroke during COVID-19-related pneumonia seems to confirm
that COVID-19 is an independent risk factor for acute ischemic stroke. The mechanisms by
which coronavirus disease leads to stroke are still under study, but it is clear that
hypercoagulability and endothelial activation play a key role. Testing for SARS-CoV-2
infection should be considered for patients who develop neurologic symptoms, but it is
equally important to monitor COVID-19 patients during their hospitalization to find any
neurological sign or symptom in a timely manner. Our case suggests that discovering
neurological deficits in sedated patients promptly can be very difficult; for this reason,
sedation in mechanically ventilated patients has to be considered only if strictly necessary.
Performing serial laboratory testing and waking up the patient as soon as clinical conditions
allow are strategies that should be taken into account.
JOURNAL
Acute Ischemic Stroke and COVID-19
Adnan I. Qureshi, William I. Baskett, Wei Huang, Daniel Shyu, Danny Myers, Murugesan
Raju, Iryna Lobanova, M. Fareed K. Suri, S. Hasan Naqvi, Brandi R. French, Farhan Siddiq,
Camilo R. Gomez and Chi-Ren Shyu
Originally published4 Feb 2021https://doi.org/10.1161/STROKEAHA.120.031786Stroke.
2021;52:905–912
Abstract
Background and Purpose:

Acute ischemic stroke may occur in patients with coronavirus disease 2019 (COVID-19), but
risk factors, in-hospital events, and outcomes are not well studied in large cohorts. We
identified risk factors, comorbidities, and outcomes in patients with COVID-19 with or without
acute ischemic stroke and compared with patients without COVID-19 and acute ischemic
stroke.
Methods:
We analyzed the data from 54 health care facilities using the Cerner deidentified COVID-19
dataset. The dataset included patients with an emergency department or inpatient encounter
with discharge diagnoses codes that could be associated to suspicion of or exposure to
COVID-19 or confirmed COVID-19.
Results:
A total of 103 (1.3%) patients developed acute ischemic stroke among 8163 patients with
COVID-19. Among all patients with COVID-19, the proportion of patients with hypertension,
diabetes, hyperlipidemia, atrial fibrillation, and congestive heart failure was significantly
higher among those with acute ischemic stroke. Acute ischemic stroke was associated with
discharge to destination other than home or death (relative risk, 2.1 [95% CI, 1.6–
2.4]; P<0.0001) after adjusting for potential confounders. A total of 199 (1.0%) patients
developed acute ischemic stroke among 19 513 patients without COVID-19. Among all
ischemic stroke patients, COVID-19 was associated with discharge to destination other than
home or death (relative risk, 1.2 [95% CI, 1.0–1.3]; P=0.03) after adjusting for potential
confounders.
Conclusions:
Acute ischemic stroke was infrequent in patients with COVID-19 and usually occurs in the
presence of other cardiovascular risk factors. The risk of discharge to destination other than
home or death increased 2-fold with occurrence of acute ischemic stroke in patients with
COVID-19.
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EVALUATION AND IMPLICATION:
A. NURSING PRACTICE
The knowledge, skills, and attitude of the nursing profession should all
be present at all times. The fundamental principles and standards must
always be followed while performing nursing activities and interventions to
ensure care quality. Learners will benefit from the nursing care plans
discussed in this presentation.
B. NURSING EDUCATION
This presentation will inform future students on the case of adults with
Cerebrovasculay Accident (CVA), how it develops, and what therapies or
medications the patient should take. This case presentation will also
encourage caregivers and other health care workers to teach about health.
C. NURSING RESEARCH
This case presentation will inspire better therapeutic management for
patients in the field of research. It will also provide future researchers with
more information regarding the progression of the disease and nursing care.

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THE COLLEGE OF MAASIN

"Nisi Dominus Frustra"

A CASE STUDY ON CONGESTIVE HEART FAILURE

Mrs. Glady’s Reina M. Maitem, RN

Faculty of the College of Nursing the College of Maasin

Andrea Alex Apego

Donnabel Kristy Garvez

BSN IV Group III

October 10, 2024

subsequently referred to LH hospital.

Address: Barangay zone III Sogod So. Leyte

Date of Birth: May 2, 1950

Age: 73 years old

Civil Status: Married

Religion: Roman Catholic

Health Care Financing: PhilHealth

B. Chief Complaint / Reason for Visit:

Body weakness right

C. History of Present Illness

The patient has type 2 diabetes and hypertension

E. Family History of Illness

side has hypertension and diabetes mellitus.

Female Father Patient

Mothers Side Fathers Side

Hypertension Diabetes Mellitus

Diabetes and Hypertension

Diabetes and Hypertension

 The patient has an altered sensorium

 Color is evenly distributed

 Head is symmetrically erect at midline

 Eyes are equally round, reactive to light and accommodating

 Irises are brown, evenly colored and typically round

 Ears are symmetrical in shape

 Symmetrical in shape with 1:2 ratio

 Respiratory rate is 15cpm

 Lower extremity edema noted + 2

GORDON’S FUNCTIONAL HEALTH PATTERN

1. Health Perception-Health Management Pattern

A. ERIK ERIKSON’S DEVELOPMENTAL STAGE

STAGE BASIC ACTUAL

B. JEAN PIAGET’S COGNITIVE DEVELOPMENT

STAGE BASIC ACTUAL

C. JAMES FOWLER’S STAGE OF FAITH

STAGE BASIC ACTUAL

FACTOR RATIONALE ACTUAL JUSTIFICATION

Obese individuals tend to have greater amounts of blood, which

ANATOMY AND PHYSIOLOGY

Structure of the Heart

Blood follows the following path through the heart:

BASIC SYMPTOMS RATIONALE ACTUAL

Dizziness If a stroke happens in the cerebellum or brainstem,

Atrophy Due to irreversible damage to the right hemisphere

Paralysis Because part of the brain is affected, particularly

injection of contrast medium.

medications and activity, as

stained smears. collection. Perform a

3. Positively identify the patient,

and time of collection.

water, GI: Nausea, respiratory