Patient’s Profile

PERSONAL DATA

Patient’s name: Mr. RBC

Religion: Roman Catholic
Nationality: Filipino
Address: Purok Iv, Dularaquen(Canique), Taytay, Palawan
Birthday: July 13, 1965
Age: 52 years old
Marital Status: Married
Physician: Dr. Jesus Nigos MD
Date of admission: December 5, 2017 (11:30pm)
Chief Complaints: Admitted due to Loss of Consciousness and Severe Headache
Final diagnosis: CVD, SUBARACHNOID HEMORRHAGE, GRADE II-III 2° TO
RUPTURED RIGHT MIDDLE CEREBRAL ARTERY ANEURYSM

PRESENT MEDICAL HISTORY

Mr. RBC is a 52 year old Filipino male, admitted with a chief complaint of Severe
Headache 10/10 and loss of consciousness he was diagnosed with CVD, Subarachnoid
Hemorrhage grade II-III.

He has undergone Craniotomy, Clipping of aneurysm last 12-07-17, Mr. RBC is

constantly recovering from the procedure he is still experiencing increased ICP and is
receiving mannitol for treatment, his speech is slow and takes time to answer but is
oriented with person, place, and time. He has Post. OP wound @ right frontal lobe
approximately 5 inches. He is on soft diet, and head of bed elevated by 40°. He has not
complained of any pain during the course of my duty.

PAST MEDICAL HISTORY

Mr. RBC has not been hospitalized before, No known allergies to food and drugs,
Immunizations cannot be remembered as it was dated back 1965, He cannot tolerate
any solid food due to difficulty in swallowing, He prefers Soft food or specifically
oatmeal. 2 days prior to admission Mr. RBC experienced Severe Headache and Loss of
consciousness, the family decided to take him to the hospital at Taytay but was referred
to MMG-Coop Hospital by his AP. Mr. RBC also experienced Fainting Spells,
Nausea/Vomiting, Cough, and Memory loss during the course of the disease.
 Patient’s Profile

Surgery

Date of Procedure: December 07, 2017

Surgeon: Dr. Jesus Nigos MD
Anesthesiologist: Dr. Karen Morales
Sterile Nurse: Avrel Verano RN
Circu Nurse: Ester Rose Taculod RN, and Mark Pacaigo
Anesthesia: General Anesthesia
Procedure: Craniotomy, Aneurysm Clipping
 Physical Assessment

BP: 140/100 mmHg PR: 65bpm

RR: 24bpm Temp: 36.4˚C

IV: PNSS 1L x 16hrs (ISOTONIC VOLUME EXPANDER/ ELECTROLYTE REPLACEMENT)

General Appearance: Received lying on bed, conscious and coherent. Slow speech, with Post Op Wound @ Right Frontal Lobe. Body Malaise Noted

Area Assessed Method Used Normal Findings Actual Findings Rationale

SKIN
Color and pigmentation Inspection Light to deep brown Light Brown Normal
Lesions Inspection No lesions, scars or inflammation No lesions, but presence of scars Normal
Texture Palpation Smooth Smooth Normal
Moisture Palpation Moist Moist Normal
Temperature Palpation The skin springs back to its The skin springs back Normal
Mobility and turgor Palpation previous state after being to its previous state Normal
pinched after being pinched
Wound Inspection No wounds Wound @ right Frontal Lobe Post Operative wound for
(Approx. 5 inches) Craniotomy

NAILS
Nail bed color Inspection Pink Pale Decrease RBC
Shape Inspection Convex Convex in the body
Lesions Inspection No inflammation of No inflammation of the Normal
Thickness Palpation the skin around the nail skin around the nail Normal
capillary refill Palpation Firm Firm Normal
Normal capillary refill Normal
Firm (less than 3secs)
 Physical Assessment

HEAD
Size Inspection Proportion to the body Proportion to the body Post op. (Craniotomy)
Symmetry Inspection and the skull is and the skull is rounded Normal
rounded and smooth and with wound at @ right frontal
Symmetrical lobe
Symmetrical
HAIR
Color Inspection Black Normal
Texture Inspection Curly hair, straight No nits/lice present Normal
Other findings Inspection No nits/lice present Normal

SCALP
Distribution of hair Inspection Evenly distributed Normal
Lesions Inspection No inflammation, No inflammation, lumps Normal
Other findings Inspection lumps or masses or masses Normal

FACE
Skin color Inspection Light to deep brown Normal
Texture Inspection Smooth Light brown Normal
Facial movement Inspection Symmetric facial Symmetric facial Normal
movement Symmetric facial
movement
EYES
External structure Inspection Evenly distributed Normal
Eyebrows Inspection Evenly distributed, Pink conjunctiva Normal
Eyelashes Inspection Evenly distributed, curved Evenly distributed Normal
Eyelids Inspection outward Evenly distributed
 Physical Assessment

EARS
Color Inspection Level of the eyes Normal
Symmetry Inspection corner Symmetric to head Normal
Shape and size Inspection Symmetric to head No discharges and Normal
No discharges and inflammation
NOSE inflammation Normal
Color Inspection Normal
Shape Inspection Same with facial color Normal
Discharges Inspection Same with facial color Symmetric Normal
Symmetric No discharges
No discharges

MOUTH Inspection Symmetric Symmetric

Lips Inspection Pink Pink Normal
Symmetry Inspection Moist Dry Normal
Moisture D/t poor
nutrition
TONGUE Positioned at the
Position Inspection center can move Central position Normal
Color Inspection freely Dull red Normal
Texture Inspection Dull red Smooth Normal
Mobility Inspection Smooth Can move freely Normal
Lesions Inspection Can move freely No lesions or Normal
No lesions or inflammation
inflammation
NECK Head centered
Position Inspection Head centered Symmetrical Normal
Symmetry Inspection Symmetrical Smooth movements Normal
Range of movements Inspection Can move freely without discomfort Normal
 Physical Assessment

Symmetric and at Normal

midline position

Thorax
Symmetry Inspection Full Symmetric expansion Full symmetric expansion upon Normal
Chest wall Palpation Chest wall is intact with no respiration Normal
Lung Sounds Percussion tenderness and masses Chest wall is intact Normal
Auscultation No presence of adventitious Client manifested Normal
sounds Bronchovesicular sound upon
auscultation

Abdomen
Color Inspection Same color with the body Color is same with the body and Normal
Contour Auscultation Symmetric Contour has symmetric contour with Normal
Symmetry of Movements Percussion Symmetric movements symmetric movements with 15 Normal
Bowel Sounds Palpation Bowel sounds 5-30 clicks clicks bowel sounds Normal

UPPER AND LOWER

EXTREMITIES
Size Inspection Equal size Equal size Normal
Symmetry Inspection Symmetrical Symmetrical Normal
Distribution of hair Inspection Evenly distributed Evenly distributed Normal
Skin color Inspection Light to deep brown Light to deep brown Normal
Lesions Inspection No lesions, No lesions, Normal
deformities or deformities or
inflammation inflammation

Strength Inspection Able to move freely, able to Needs assistance in moving, Neuromuscular
maintain grip cannot maintain grip impairment
 Physical Assessment

Temperature Inspection 36.5-37.5°C 36.5°C Normal

Pain Inspection No pain No pain Normal

Source: E.Burns, K.Korn, J.Whyte(2011)Clinical Examination and practical skills

 Physical Assessment

GLASGOW COMA SCALE

4 SPONTANEOUS
3 TO VOICE
EYE OPENING 2 TO PAIN 4
1 NONE
5 ORIENTED
4 CONFUSED
VERBAL RESPONSE 3 INAPPROPRIATE 5
2 INCOMPREHENSIBLE
1 NONE
6 OBEYS COMMAND
5 LOCALIZED PAIN
MOTOR RESPONSE 4 WITHDRAWS FROM
PAIN 6
3 DECROTICATE
POSTURING
2 DECEREBRATE
POSTURING
1 NONE
TOTAL 15
RESULTS: Severe Brain Injury (3-8) Moderate Brain Injury (9-12), Mild Brain Injury (13-14), Healthy (15)
 Drug Study

DRUG DATE CLASSIFICA DOSE MECHANISM OF INDICATION SIDE EFFECTS NURSING

TION AND ACTION CONSIDERATI
ROUTE ON

Generic Decem Osmotic 100mg IV Increases osmotic Test dose for CNS: dizziness, 1. Assesss
Name: ber 16, Diuretic push pressure of plasma marked oliguria headache, skin turgor,
Mannitol 2017 in glomerular or suspected seizures mucous
filtrate, inhibiting inadequate renal CV: chest pain, membranes
tubular reabsorption function, prevent hypotension, and mental
of water and acute renal failure hypertension, status
electrolytes during tachycardia, before
(including sodium cardiovascular thrombophlebitis, administrati
and potassium). and other heart failure, on of drug.
These actions surgeries, acute vascular overload 2. Assess
enhance water flow renal failure, to EENT: blurred signs for
from various tissues reduce vision, rhinitis electrolyte
and ultimately intracranial GI: nausea, imbalance.
decrease intracranial pressure and vomiting, 3. Monitor
and intraocular brain mass, diarrhea, dry Vital signs
pressures. reduce mouth including
intraocular GU: polyuria, central
pressure, to urinary retention, venous
promote dieresis osmotic nephrosis pressure
in drug toxicity, Metabolic: and output.
irrigation during dehydration, 4. Store at
transurethral water room
resection of intoxication, temperature
prostate. hypernatremia, .
hyponatremia, 5. Use a filter
hypovolemia, with
hypokalemia, concentrate
Drug Study

hyperkalemia, d mannitol
metabolic acidosis (15%, 20%
Respiratory: and 25%).
pulmonary 6. Be alert for
congestion adverse
Skin: rash, reactions
urticaria and drug
Other: chills, interactions.
fever, thirst, 7. Monitor
edema, hepatic and
extravasation renal
with edema and function
tissue necrosis during
therapy.
8. Monitor IV
site
carefully to
avoid
extravasatio
ns and
tissue
necrosis
9. Do not add
to other IV
solutions or
mix with
other
medications
.
10. Watch for
excessive
Drug Study

fluid loss
and signs
and
symptoms
of
hypovolemi
a and
dehydratio
n.
11. Assess for
evidence of
circulatory
overload,
including
pulmonary
edema,
water
intoxication
, and heart
failure.
 Drug Study

DRUG DATE CLASSIFICAT DOSE MECHANISM INDICATION SIDE EFFECTS NURSING

ION AND OF ACTION CONSIDERATI
ROUTE ON
Generic Dece 250mg Acetazolamide is an It Contraindication:
is used to get rid -Depression
Monitor individuals1. Monitor
Name: mber Carbonic TAB hypersensitivity
enzyme inhibitor that of extra fluid. to -Tiredness
taking acetazolamide individuals
16, Anhydrase Q5° acts particularly on carbonic anhydrase - Body with
malaise
primidone and taking
Acetazolamide 2017 Inhibitor. carbonic anhydrase. inhibitor -Drowsiness
carbamazepine.
and acetazolami
Carbonic anhydrase is It is used to treat or
Hypersensitivity toconfusion
Acetazolamide may de with
the enzyme that prevent altitude
sulfonamides - Transient
increase the blood primidone
converts carbon sickness.
Depressed levels ofnearsightedness
levels of and
dioxide and water to serum potassium and-Anorexia carbamazepine and carbamazep
carbonic acid sodium - Metallic
quinidine
tasteand may ine.
(H2CO3). Carbonic It is Marked
used to help
kidney and-Nausea
decrease
andthe blood Acetazolam
anhydrase inhibitors, control certain kinds vomiting
liver disease levels of primidone. ide may
such as of seizures.
Suprarenal grand Instruct the patient to increase the
Acetazolamide failure avoid taking aspirin blood levels
inhibits carbonic Hyperchloremic with Acetazolamide. of
It is used to treat
anhydrase in the disease Increase in side effects carbamazep
glaucoma.
tissues and fluid thus, First trimester of such as drowsiness, ine and
decreasing carbonic pregnancy confusion, lethargy, quinidine
acid in the body. Concurrent
It may be given to use of hyperventilation and and may
In the eye, the youophthalmic
for other carbonic ringing in the ears decrease the
inhibitory action of anhydrase
reasons. Talkinhibitors
with when acetazolamideis blood levels
Acetazolamide (brinzolamide,
the doctor. taken with aspirin. of
decreases the dorzolamide) Monitor electrolyte primidone.
secretion of aqueous . Adrenal gland levels 2. Instruct the
humor that lowers the failure (Addison’s patient to
intraocular pressure disease) avoid
which is desirable in Sickle cell anemia taking
glaucoma. In the Chronic non- aspirin with
central nervous congestive Acetazolam
 Drug Study

system (CNS), ide.

restrained carbonic Side effects: Increase in
anhydrase retards the Depression side effects
abnormal and Tiredness such as
paroxysmal excessive Body malaise drowsiness,
discharge from the Drowsiness and confusion,
neurons of CNS. confusion lethargy,
In the kidneys, Transient hyperventil
carbonic acid nearsightedness ation and
Anorexia ringing in
Metallic taste the ears
Nausea and when
vomiting acetazolami
deis taken
with
aspirin.
3. Monitor
electrolyte
levels
 Drug Study

DRUG DATE CLASSIFICAT DOSE MECHANISM INDICATION SIDE EFFECTS NURSING

ION AND OF ACTION CONSIDERATI
ROUTE ON
Generic Dece psychostimula 1g IV q6° Contraindication: citicoline
Citicoline activates the Cerebrovascular Monitormayindividuals
1. Watch out for
Name: mber nt biosynthesis of hypersensitivity
Diseases, toexerttaking
a acetazolamidehypotensive
16, structural carbonic anhydrase
accelerates the stimulating
with primidone
action andeffects
citicholine 2017 inhibitor
phospholipids in the recovery of of the
carbamazepine. 2. Somazine must
Hypersensitivity toparasympathetic,
neuronal membrane, consciousness Acetazolamide maynot be
increases cerebral sulfonamides
and overcoming as well
increase
as a the blood administered
metabolism and motorDepressed
deficit. . levels offleeting
levels
and
of along with
increases the level of serum potassium anddiscrete carbamazepine and medicaments
various sodium hypotensor
quinidineeffect
and may containing
neurotransmitters, Marked kidney and decrease the blood
including liver disease levels of primidone.
acetylcholine and Suprarenal grand Instruct the patient to
dopamine. Citicoline failure avoid taking aspirin
has shown Hyperchloremic with Acetazolamide.
neuroprotective disease Increase in side effects
effects in situations of First trimester of such as drowsiness,
hypoxia and ischemia. pregnancy confusion, lethargy,
Concurrent use of hyperventilation and
ophthalmic carbonic ringing in the ears
anhydrase inhibitors when acetazolamideis
(brinzolamide, taken with aspirin.
dorzolamide) Monitor electrolyte
Adrenal gland levels
failure (Addison’s
disease)
Sickle cell anemia
Chronic non-
congestive
Drug Study

Side effects:
Depression
Tiredness
Body malaise
Drowsiness and
confusion
Transient
nearsightedness
Anorexia
Metallic taste
Nausea and
vomiting
 Drug Study

DRUG DATE CLASSIFICAT DOSE MECHANISM INDICATION SIDE EFFECTS NURSING

ION AND OF ACTION CONSIDERATI
ROUTE ON
Generic Dece Calcium 30 mg / Calcium channel Contraindication:
Prophylaxis and Severe
Monitor
BP individuals1. Take apical
Name: mber channel tab 2 tabs blocking agent that is hypersensitivity
treatment of tolowering,
takingGIacetazolamidepulse prior to
16, blocker q6 relatively selective for carbonic anhydrase disturbances,
ischemic with primidone andadministering
Nimodipine 2017 cerebral arteries inhibitor
neurological deterioration
carbamazepine.
of drug and hold
compared with Hypersensitivity
deficits due to torenalAcetazolamide
function, mayit if pulse is
arteries elsewhere in sulfonamides
cerebral disturbances
increase the
of blood below 60.
the body. This may be Depressed
vasospasms levels ofheart
after levels
rhythm,
of notify the
attributed to the serum potassium andphlebitis,
subarachnoid carbamazepine
increase and physician.
drug’s high lipid sodium
hemorrhage of liver
quinidine
enzymes.and may
2. Establish
solubility and specific Marked kidney and decrease the blood baseline data
binding to cerebral liver disease levels of primidone.before
tissue. Suprarenal grand Instruct the patient to
treatment is
failure avoid taking aspirinstarted.BP,
Hyperchloremic with Acetazolamide.pulse and
disease Increase in side effects
laboratory
First trimester of such as drowsiness, evaluations of
pregnancy confusion, lethargy, liver and
Concurrent use of hyperventilation and kidney
ophthalmic carbonic ringing in the ears function.
anhydrase inhibitors when acetazolamideis
3. Monitor
(brinzolamide, taken with aspirin. frequently for
dorzolamide) Monitor electrolyte adverse drug
Adrenal gland levels effects,
failure (Addison’s including
disease) hypotension,
Sickle cell anemia peripheral
Chronic non- edema,
congestive tachycardia, or
Drug Study

skin rash.
Side effects: 4. Monitor
Depression frequently
Tiredness for dizziness
Body malaise or
Drowsiness and lightheaded
confusion ness in older
Transient adult, risk of
nearsightedness hypotension
Anorexia is increased.
Metallic taste
Nausea and
vomiting
 Laboratory

Procedure(POST OP) Result Normal Values Clinical Significance Nursing Implications

HGB 131 M: 140-180 g/L A Low hemoglobin level 1. Explain test procedure.
(L) indicates anemia. Estimates of Explain that slight
Hgb in each RBC are discomfort may be felt
moderately important when when the skin is
determining the total blood punctured.
Hgb. However, hemoglobin 2. Encourage to avoid stress
findings are even more if possible because
dependent upon the total altered physiologic status
number of RBC's. In other influences and changes
words, for the diagnosis of normal hematologic
anemia, the number of RBC's values.
is as important as the 3. Explain that fasting is not
hemoglobin level. necessary. However, fatty
HCT 0.394 0.400-0.540 If the Hct is abnormal, then meals may alter some test
(L) the RBC count is possibly results as a result of
abnormal. If the RBC count lipidemia.
turns out to be normal, then 4. Apply manual pressure
the average size of the RBC is and dressings over
probably too small. Shock, puncture site on removal
hemorrhage, dehydration, or of dinner.
excessive IV fluid 5. Monitor the puncture site
administration can reduce the for oozing or hematoma
Hct. formation.
6. Instruct to resume normal
activities and diet.
 Laboratory

RBC count 4.1 4.60-6.00 X 1 This test can also give an 1. Explain test procedure.
(L) indirect esti-mate of the Explain that slight
hemoglobin levels in the discomfort may be felt
blood. RBC's are actually "Red when the skin is
Blood Corpuscles," (non- punctured.
nucleated cells). The term 2. Encourage to avoid stress
corpuscle indicates that it is a if possible because
mature Red Blood Cell. Once altered physiologic status
the immature cell has influences and changes
matured, it is then, and only normal hematologic
then, capable of carrying values.
oxygen. It is then also not 3. Explain that fasting is not
"technically" a cell anymore. necessary. However, fatty
Once it has matured, it loses meals may alter some test
its nucleus and can no longer results as a result of
be properly termed a cell. It lipidemia.
would be called a corpuscle. 4. Apply manual pressure
However, everyone still refers and dressings over
to them as RBC's (cells). The puncture site on removal
source of the specimen is of dinner.
whole blood, capillary, or 5. Monitor the puncture site
venous blood. for oozing or hematoma
formation.
6. Instruct to resume normal
activities and diet.
 Laboratory

Lymphocytes 12 20.0-40.0% Increased by: Infection; 1. Explain test procedure.

(L) gonorrhea, osteomyelitis, Explain that slight
otitis media, chickenpox, discomfort may be felt
herpes, others Ischemic when the skin is
necrosis due to MI, burns, punctured.
carcinoma Metabolic 2. Encourage to avoid stress
Disorders; diabetic acidosis, if possible because
eclampsia, uremia, altered physiologic status
thyrotoxicosis Stress influences and changes
Response; due to acute normal hematologic
hemorrhage, surgery, values.
emotional distress, others 3. Explain that fasting is not
Inflammatory disease; necessary. However, fatty
rheumatic fever, acute gout, meals may alter some test
vasculitis, myositis Decreased results as a result of
by: Bone marrow depression; lipidemia.
due to radiation or cytotoxic 4. Apply manual pressure
drugs Infections; such as and dressings over
typhoid, hepatitis, influenza, puncture site on removal
measles, mumps, rubella of dinner.
hypersplenism; hepatic 5. Monitor the puncture site
disease, storage disease for oozing or hematoma
Collagen vascular disease; formation.
systemic lupus erythematosus 6. Instruct to resume normal
Deficiency of; folic acid or activities and diet.
vitamin B12
 Laboratory

WBC 11.34(Leukocytosis) 4.3-10.0 x 109 An increased total WBC count Observe universal precautions
(H) (leukocytosis: WBC 10,000) when collecting a blood
usually indicates infection, specimen.
inflammation, tissue necrosis, or • Check whether fasting is
leukemic required. Many studies, such
neoplasia. Trauma or stress, as
either emotional or physical,
fasting blood sugar and
may increase the WBC count. A
cholesterol levels, require
decreased total WBC count
fasting
(leukopenia: WBC 4000) occurs
in many forms of bone marrow for a designated period of
failure (e.g., after antineoplastic time. Water is permitted.
chemotherapy or radiation • If ordered, withhold
therapy, marrow infiltrative medications until the blood is
diseases, overwhelming drawn.
infections, • Record the time of day
dietary deficiencies, and when the blood test is drawn.
autoimmune diseases). Some
blood test results (e.g., those
for cortisol) vary according
to a diurnal pattern, and this
must be considered when
blood levels are interpreted.
• In general, two or three
blood tests can be done per
tube
of blood collected (e.g., two or
three chemistry tests from
one red-top tube of
blood).
Note the patient’s position for
certain tests (e.g., renin,
because levels are affected by
body position).
• Collect the blood in a
Laboratory

properly color-coded test

tube.
Blood collection tubes have
color-coded stoppers to
indicate
the presence or absence of
different types of additives
(preservatives and
anticoagulants). A
preservative prevents
change in the specimen, and
an anticoagulant inhibits clot
formation or coagulation.
Charts are available from the
laboratory
indicating the type of tube
needed for each particular
blood test.
• Follow the recommended
order of draw when collecting
blood in tubes. Draw
specimens into nonadditive
(e.g.,
red-top) tubes before drawing
them into tubes with
additives.
This prevents contamination
of the blood specimen
with additives that may cause
incorrect test results. Fill the
tubes in the following order:
1. Blood culture tubes (to
maintain sterility)
2. Nonadditive tubes (e.g.,
Laboratory

red-top)
3. Coagulation tubes (e.g.,
blue-top)
4. Heparin tubes (e.g., green-
top)
5. Ethylenediaminetetraacetic
acid (EDTA) tubes (e.g.,
lavender-top)
6. Oxalate/fluoride tubes (e.g.,
gray-top)
• To obtain valid results, do
not fasten the tourniquet for
longer than 1 minute.
Prolonged tourniquet
application
can cause stasis and
hemoconcentration.
• Collect the blood specimen
from the arm without an
intravenous
(IV) device, if possible. IV
infusion can influence
test results.
• Do not use the arm bearing
a dialysis arteriovenous fistula
for venipuncture unless the
physician specifically
authorizes
it.
• Because of the risk of
cellulitis, do not take
specimens from
the side on which a
mastectomy or axillary lymph
Laboratory

node
dissection was performed.
• Follow the unit guidelines
for drawing blood from an
indwelling venous catheter
(e.g., a triple-lumen catheter).
Guidelines will specify the
amount of blood to be drawn
from the catheter and
discarded before blood is
collected
for laboratory studies. The
guidelines will also indicate
the
amount and type of solution
needed to flush the catheter
after drawing the
blood to prevent
clotting.